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state of California—Health and Welfare .ncy <br /> Department of Health Services <br /> PRIORl)'Y O <br /> (Explain) HML No. <br /> HAZARDOUS MATERIALS SAMPLE ANALYSIS REQUEST <br /> PART I: FIELD SECTION <br /> Collector -- - Date Sampled <br /> LOCATION OF SAMPLING : Time '`•f ' Hours <br /> Name �— <br /> Tel. No. <br /> Address I (T.i - <br /> Number street State <br /> 21P <br /> HML No. Collector's Type Of <br /> (Lab Only) _ Sample No. Sample' FIELD INFORMATION" <br /> � t '�� •r. f ,a�tut ; �^..tri � r ;,+ ! r , . <br /> 1!,..y 1 L 1 1 <br /> I y t } <br /> Analysis Requested: : .r't. - %k1/.i 4� !t�: <br /> Chain of Custody:. <br /> 519nature <br /> Title <br /> 2. •Inclusive Dates <br /> signature — <br /> 3. <br /> ^Tive Inclusive Dates <br /> signature — <br /> Title .Inclusive Dates <br /> 519nature Title <br /> Special Remarks <br /> Inclusive Dates <br /> (e•9.,tluPllcate sample given to company.etc.) <br /> ART II: LABORATORY SECTION <br /> .eceived BY - Title - 1 <br /> ample Allocation: ❑ HML ❑ SCBL ❑ LBLDate <br /> ❑ Other Date <br /> nalysis Required <br /> ndicate whether sample is sludge, soil, etc.,- Use back of page for additional information.- <br /> , 8002 (5/Ani <br />