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Sta(e of Californ!a-Naalth and Walfara Agency Department of Health Services <br /> N.AZA....,OUS MATERIALS SAftiMPLE ANALYSIS REt�iEST <br /> PRIORITI"�� " HNIL No,h <br /> (Explain) _ . _ M To <br /> low- <br /> PART I: FIELD SECTMN <br /> Collector � t�� �.l`-e.R Date Sampled 2 ' <br /> Time Hours <br /> Activity: 1 Enforcement ❑ ASP ❑ H.W. Property ❑ Super ❑ Other ❑ RCRA OPT Code <br /> Region: ❑ PMS-SAC [ ) NCS-SAC ❑ NCS-FRESNO ❑ SCS-LA ❑ NCCS-BERK <br /> LOCATION OF SAMPLING: <br /> Name — Tel. No. <br /> Address 3 S GV. �G�•� t�� �� ��ti�u <br /> Number Street j City Zip <br /> HML No. Collector's Type Of <br /> (Lab Only) Sample No. Sample" FIELD INFORMATION <br /> v�� � +,J(,Y't_�.• �b�'� 1 ,dt W�+h A�(�g -Q� 5 b r 1 � 2��r'-�yL� <br /> �'a ah s. <br /> tI* I , <br /> Analysis Requested: <br /> V o <br /> Chain of Custody: / <br /> SI n re T—Title Inclusive Dates <br /> J <br /> Signature Title Inclusive Dates <br /> Signature Title Inclusive Dates 4.—Signature Title Inclusive Dates <br /> 5. _ L' <br /> Signature Title Inclusive Dates <br /> Special Remarks is <br /> s; <br /> (6.g.,duplicate sample given to company,etc.) <br /> PART II: LABORATORY SECTION <br /> ReceivedBy �-�- �~ <br /> Title \ ��-� Date <br /> Sample Allocation: ❑ HN4L ❑ SCBL ❑ LBL ❑ Other Date t <br /> Analysis Required <br /> ,-._-- ____---_ ^• —•�= —`-- ---- - --_sem-.�--_--- <br /> `Indicate Whether sample is sludge,soil,etc. 3 Orifi.-Lab. Dup.-,File Trip.-Inspector <br /> 01 IS 8002 (9/84) <br /> i <br />