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HAZARDOUS MATERIAL, I <br />0APADI G AMAI Y�IS REQ E_ <br />i. ColleUor/Address <br />PICA+_� A m\0ab_)er <br />6. Cate Sampled I 1_ 1 —U� <br />�� I I <br />A!1 app;,cabte Mems of <br />must be completed I ro <br />a. Phone (2 {`] -�{q �j 5 Priority <br />a. Authorized by <br />PI Co-,� D�- <br />ll^7 1Hours 8. Coces (fill in all applicable codes) <br />7. Time Sampled I C� � r , <br />a. STC O 3 C I:_I <br />❑ Ali Tech C] Omer <br />9. Activity Ent ❑ Sury ❑Site �l ❑Permitting b. Reg On . - <br />{ <br />10. SAMPLING LOCATION <br />e. Type <br />b. Site uY1 101 t ��C' <br />. c. Address <br />Number <br />= <br />11. SAMPLES - <br />{vom 5 us e <br />a- ID b. Collector's No. <br />C. HML N <br />l A. 23►101—OI <br />B. :.S 64 0011 0a, <br />C: <br />D. <br />f. ❑ PCB <br />—E.- <br />—E.F, <br />(Screeng) <br />F,a <br />G. <br />g. ❑ VOA <br />Pesticides <br />a..... ....... <br />12.7ANALYSIS REQUESTED <br />a.�❑ pH .. <br />h. ❑ PAH <br />b. ❑ Metal <br />Pesticides <br />Scan <br />c,.Q Metals - - <br />----r❑Carba- <br />(Spec) <br />o.❑ <br />d. ❑ W. T. <br />13. CHAIN OF CUSTODY <br />— <br />Signature <br />b. =T t <br />I Signature <br />d. . <br />Signature <br />14. SPECIAL REMARKS <br />•15. RECEIVED BY - <br />-16. SAMPLE ALLOCATION a- <br />-17 <br />• <br />`17 -ANALYSIS REQUESTED <br />OHS 8002 (Rev 7/87) <br />C. TPC <br />a. EPA ID No d. INDEX LO <br />e. PCA O O u <br />f f. SITE <br />g. County <br />eel-- <br />___� Container <br />f Size g. Field Information <br />d. Type <br />e. Type <br />�t-z2C <br />-5o lid <br />_ <br />{vom 5 us e <br />k. ❑ Ext. 0 r <br />f. ❑ PCB <br />(Screeng) <br />1. ❑Chlorinated <br />g. ❑ VOA <br />Pesticides <br />- <br />M. ❑ Organo -P <br />h. ❑ PAH <br />Pesticides <br />I. Phenols <br />n Asb�s <br />----r❑Carba- <br />o.❑ <br />- mates - <br />�- ch 4/775� <br />Name,Titie 7 <br />N e, Title +w <br />Ind L a) t+l��'� ILLm <br />y'– NamelTitle ' <br />Name/Title <br />Title �Q <br />b. Date <br />L -Berkeley b. ❑ _HML-SC Ic. ❑ AIHL d. ❑ Contract b. Date <br />Original -Lab Duplicate -File • Triplicate -Inspector <br />A,8 <br />inclusive Dates <br />. � t <br />Inclusive Dates <br />elusive Oates <br />Inclusive Dates <br />NLY (NA9L1 <br />