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State of California—Health and Welfare Agency Department of Health Services <br /> HAZARDOUS MATERIALS SAMPLE ANALYSIS REQUEST <br /> PRIORITY � HML No. <br /> To <br /> (Explain) <br /> PART I: FIELD SECTION <br /> Collector Date Sampled Time Hours <br /> Activity: ❑ 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 <br /> Number Street City Zip <br /> HML No. Collector's Type Of <br /> (Lab Only) Sample No. Sample* FIELD INFORMATION <br /> Analysis Requested: <br /> Chain of Custody: <br /> 1 Signature Title Inclusive Dates <br /> 1.1c �. T _ <br /> 2 Signature Title Inclusive Dates <br /> 3 Signature Title Inclusive Dates <br /> 4. <br /> Signature Title Inclusive Dates <br /> 5 Signature Title Inclusive Dates <br /> Special Remarks <br /> (e.g.,duplicate sample given to company,etc.) <br /> PART II: LABORATORY SECTION <br /> Received By Title Date <br /> Sample Allocation: ❑ HML ❑ SCBL ❑ LBL ❑ Other Date <br /> Analysis Required <br /> *Indicate whether sample is sludge,soil,etc. <br /> Orig.—Lab. Dup.—File Trip.—Inspector <br /> DHS 8002 (9/84) <br />