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State of California -California rEnvironmental Protection Agency <br />7 <br />Department of Toxic Substances Control <br />Hazardous Materials Laboratory <br />HAZARDOUS MATERIALS <br />1. Authorization Number <br />HML No <br />2. Page <br />N <br />pN <br />M <br />� <br />q <br />(o <br />(� <br />SAMPLE ANALYSIS REQUEST <br />To 1 �� <br />of <br />3. Requester: A I A r1 K J <br />4. Phone N ;2, 'S- - 3k; ;L % <br />5. Priority Level: <br />1 3 <br />Address (To Receive Results):/o/ 5 r'rQc�o�at 4ij,SL 5 e�Y� S� Z 7 <br />a. Authorized <br />by <br />6. Date Sampled <br />7. Time Sampled a Hours 8. Codes (fill in all applicable codes) <br />a. STC .'� <br />c,i O C'. <br />9. Activity: Q SEB ❑ SMB <br />E] FPB E] FMB ❑ HQ E] OTHER <br />b. Region <br />10. SAMPLING LOCATION Ll <br />I I I I I I I I I I <br />c. INDEX <br />( Q <br />a. EPA ID No. <br />d. PCA 3 <br />(o ;2t C) <br />? A) �- C'G» Cn <br />f4 ✓ r S <br />b. Site <br />o <br />e. MPC <br />f. SITE <br />d O O <br />1 <br />4 <br />Address !UU �� see rCAv_f �<<Lv1 <br />g. County <br />c. <br />Number <br />Street City " Zip <br />11. SAMPLES <br />Sample Container <br />a. ID b. Collector's No. <br />c. Lab No. d. Tye e. Type <br />f. Size <br />Field Information <br />B <br />C <br />F <br />D <br />E <br />E <br />L <br />F <br />D <br />G <br />H <br />12. ANALYSIS REQUESTED <br />f. ❑ VOA -8020 <br />I. ❑ Flash <br />Point <br />a. g?pH <br />g. ❑ VOA-H/S <br />m. ❑ C1 -Pes- <br />ticides <br />b. [/ Metal <br />h. ❑ VOA -8240 <br />n. ❑ OP-Pes- <br />Scan <br />ticides <br />c. ❑ Metals <br />i. ❑ VOA -8260 <br />0. ❑ <br />(Spec) <br />d. ❑ W.E.T. <br />j. ❑ SVO-8270 <br />P. ❑ <br />e. �OA-8010 <br />Diesel/ <br />k. ❑ Gasoline <br />q: ❑ <br />13. SPECIAL REMARKS: <br />F. <br />.:O <br />y�, <br />F:i'':%l# £ <br />F. <br />• ,: , S: <br />x}s�!•: � of Fi •F. : <br />+ . NF :i ? •: <br />IM <br />i ,eh"fJ <br />: J <br />...:.'?.::J:.> ............. ..'.. .ui �:y:>;:#':kr.};?:;i.; :;:.xo ;J' S <br />.. ..{.....v........ ............. ..:. ........ ,. . <br />p : <br />:?'V :.o �• F. e .. <br />.? � .Ji� .J�44. f. v.:::v:•. Y <br />''O : � J.?i:Yi;}[:: <br />....... ::::::� <br />•.i.'J <br />15. CH %�pF CUSTODY/ <br />✓`�- '� <br />/. <br />_ ,i/.4, ezly A06; <br />S <br />7 <br />a. <br />gnature <br />a /Title <br />"7�trVllak���' <br />Inclusive Dates <br />I 1 <br />b.C.1. <br />Signature <br />Name/Title <br />Inclusive Dates <br />C. <br />- <br />Signature <br />Name/Title <br />Inclusive Dates <br />d. <br />Signature <br />Name/Title <br />Inclusive Dates <br />16. LAB REMARKS: <br />L <br />A <br />B <br />DTSC 1116 (REV. 1/94) Original -Lab a Duplicate -File • Triplicate -Inspector NLY (HML) <br />(Formerly DHS 8002) <br />