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PRIORITY 0 Department of Health Services <br /> (Explain) <br /> ------------ <br /> HML No. <br /> —�9 0 <br /> HAZARDOUS MATERIALS SAMPLE ANALYSIS REQUEST / <br /> TI: FIELD SECTION <br /> Collector — ( -- • ,. r <br /> LOCATION OF SAMPLING : Date Sampled -'� <br /> Name "i ,. ;,-a... Time '-ice' amours <br /> Tel. No. <br /> Address �� - `���` 47Y _ <br /> S� <br /> Street tater' <br /> HML No. Collector's Type Of zip <br /> (Lab Only) Sample No <br /> �--- --�_ Sample <br /> '- FIELD INFORMATION" <br /> (r,✓l� l ,J,ttt{ <br /> Ffri tri/t�� ( 'll <br /> f� ( r <br /> --��'�— <br /> N <br /> Analysis Requested rP, LV)1 4j <br /> � . — <br /> J <br /> ' K I / { ' t 11, <br /> Chain <br /> Ir"(! <br /> Chain of Custody:I ' 4 <br /> Title Inclusive Dates <br /> bignature <br /> Title <br /> 3. <br /> Inclusive Datez <br /> Signature Title <br /> 4. <br /> Inclusive Dates <br /> Signature <br /> Title <br /> Special Remarks Inclusive Dates <br /> (e.g.,tluplicate sample given to company,etc.) <br /> PART II: LABORATORY SECTION <br /> Received By <br /> Title Date <br /> tampleAllocation: ❑ HML ❑ SCBL ❑ LBL 13Other <br /> ( Date <br /> malysis Required '- <br /> r � • <br /> \ <br /> C- <br />'ndicate whether sample is sludge, soil, etc.; Use back of page for additional information.; <br />-IS 8002 (5/80) Ori <br /> g.—Lab. Dup.—File Trip.—Inspector <br />