Laserfiche WebLink
S41e Of CallfOrnla—Healln no Welfare Agency <br /> HAZA, .US MATERIALS SAMPLE ANALYSIS RE( 3T Department of Healtn Serrlces <br /> PRIORITY <br /> (Explair4 �) HML No J _ <br /> /� To <br /> PART 1:_.F IELD SE_CTI.ON_ _ / C_ ]--( D (� -7 L' 4 3 <br /> Collector C—( Cl l.t C(( !,- GU [L Date Sampled )" ryQAS_Cl L ) Time Hours <br /> Activity: A Enforcement ❑ ASP ❑ H.W. Property ❑ Super ❑ Other ❑ RCRA OPT Code <br /> Region: ❑ PMS-SAC 14 NCS-SAC ❑ NCS-FRESNO ❑ SCS-LA ❑ NCCS-BERK <br /> LOCATION OF SAMPLING: <br /> Nam <br /> ^^c (.-. ,n r Tel. NoAn9 - 33c/b'O c) <br /> Address �Ch-� V( t_4 r, f 1 r )--cCl t <br /> Number Street City Zip <br /> HML No. Collector's Type Of <br /> (Lab Only) Sample No. Sample' FIELD INFORMATION <br /> 1 <br /> Le1P F t.•njc( C ' nrr f OlItirl <br /> Analysis Requested: _7 1 �'!>i".Z, //y6....7 i-1, / ri <br /> i <br /> -pain of Custody: . <br /> Ignature TI <br /> ' r Intlutive Dates ( <br /> 2�..2 � u <br /> 19naur� — Title _ <br /> 11!! �' I !� Inclusive Dates <br /> :2 <br /> Signature — <br /> Tlpe Indus!ve Oases ! <br /> Signe W re Tltic <br /> Induslvt Dates <br /> I <br /> Signature Title Inclusive Dates <br /> Decial Remarks <br /> (e.g..eupllcate sample glven to company,etc.) <br /> ART If: LABORATORY SECT.i N <br /> ^ceived By __ Title- / C Date -,� li <br /> ample Allocation: ❑ HML <br /> El ❑ LBL <br /> ❑ Other , Date i <br /> '/ / e <br /> Talysis Required�/y� -��LC nr...✓i, -,. Ii <br /> t <br /> { <br /> dicate Whether sample is sludge, soil, etc. <br /> Oiig.-Lab. Dup.-Filo Trip.-Inspector <br /> 5 8002 (9/64) _.. <br />