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State of California-California.Environme al Pro n Agency Department of Toxic Substances Control <br /> -- ---- -- - - -- <br /> Hazardous-MateriaisLaboratory- -- <br /> HAZARDOUS MATERIALS 1. Authorization Number HML No. 2. Page <br /> SAMPLE ANALYSIS RE-QUEST w - 6 To 1 I of <br /> ) _ <br /> 3. Requestgr: L 1 I Cr V, �� 4.- Phone (S�%!) S f`o-3�7S 7. TAT Level: (check one) <br /> � Off' <br /> 5. Address (Ta Receive Results): 6. FAX ( ) �2 I El. a <br /> /�'�. .2dp <br /> 4 Y� 7`CI "Unit Chiefs Signature <br /> 8. Date Sampled: 9. Codes (fill in !�4 <br /> pplicable codes). <br /> 7 Z a.. Office <br /> 1U. Activity:FISCD ❑'SRPD` ❑ SMB ❑ FPB' ❑ SPPT ❑ ER/CL ❑ Others b <br /> y� b. INDEX O11..SAMPLING LOCATION rt - 'O' 0 D / O D c. PCA <br /> a. EPAID No. 2 1 dJ MPC <br /> b: Site- � �c._ Address , SITE 0 -� 2 <br /> Number Street' - City ZIP f. County <br /> 12. SAMPLES: _ <br /> Sample Container <br /> a. ID b-. Collector's No.-.,'.-, Lab:No_ Type e: Type f. Size g: Field-Information <br /> s' o <br /> E S 13 O t L-l = ,• tt" . t, �n�- 6�s.fyE` <br /> F M <br /> Q � - <br /> 13. ANALYSIS REQUESTED: (X desired analysis and enter I.D.'s from 12.a.) <br /> INORGANIC ANALYSIS Sample(s) ID - ORGANICS ANALYSIS "' ' Sarriple(s) ID <br /> Metals.Scan-(6010)-.'_-;7:-4 C f' CL-Pest (8081) _ <br /> Metal(s) Specific: OP-Pest.(8141) <br /> WET PCBs-(8082); I� <br /> pH G R_0.(8.01.5B)- - -T- . -- - -- - <br /> Cyanides - " D R O/ Motor Oil (HML 816) <br /> (others,write in zS::,= n-Hexane-Extractables (1664) <br /> ash-Point' 1020 <br /> (others,write in Fl <br /> - - (: ) <br /> TCLP'Analysis -:.- - - - VOCS1ncluding 6fEX Qece <br /> 7-- <br /> SVOCs-(8270)-(sea,tootnotes)-.: (onla ) :(do TCLP regardless) ^' <br /> Metals __ ___. .. -- - PAHs (8270)_ <br /> - Mercury -- - - - -- -- <br /> Volatiles (others,write in) " <br /> _ Semivolatiles (others,write in) <br /> --- (others,write in) - - - -- - --- ---— ---- (others,write in) -- • <br /> 14. Analysis Objective: Drinking H.0 Standards. (applies to DW only) Treatment Standards <br /> (check box)-- - - <br /> Waste Characterization PRG"s Others _ (contact Lab supervisors if needed) <br /> 15. Detection Limit Requirements.- <br /> (Specify <br /> equirements(Specify if known and contact lab) <br /> r <br /> Initials- - - - <br /> -16. SUPPLEMENTAL <br /> REQUESTS- El <br /> Dat <br /> e - - <br /> 17. CHAIN OF CUSTOQY=. ir• -- U. 11- -- <br /> a: AMZaP_r e�tle Incl swe Dates .•-_ <br /> i <br /> Si p lure p r a /'� rv� . <br /> b. Q CQ no <br /> Signature Name/Tittle Inclusive Dates <br /> C. NameMtie: Inclusive Dates <br /> _ Signature .. _ ... _ _ <br /> -. <br /> 18. LAB REMARKS <br /> --- - - <br /> DTSC 1116 (REV 3/99) Original-Lab Duplicate-File•Triplicate-Inspector NLY <br />