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State of California -California Environmental Protection Agency <br />HAZARDOUS MATERIALS <br />SAMPLE ANALYSIS REQUEST <br />3. Requester. A i A -n K• :T -i-,) <br />Address (To Receive Results):/o/s 2a4�vd;d, <br />6. Date Sampled <br />1. Authorization Number <br />� iA LA a. q 6 <br />4. Phone (q/b );Z65- -319a7 <br />✓t.7,SkLt 3 ; S . CJt SSb Z 7 <br />7. Time Sampled a Hours <br />1 9. Activity: ® SEB ❑ SMB ❑ FPB ❑ FMB ❑ HQ ❑ OTHER 1 <br />10. SAMPLING LOCATION <br />a. EPA ID No. <br />b. Site ?—A) <br />Dqwrwwm of Toxic Substances Control <br />HaurdowMaterialls, Laboratory <br />HMLN Z Page / <br />Tom= o>f t <br />5. Priority. 1: 0 <br />a. Authorized by <br />8. Codes (fill in all applicable odes) <br />a. STC ,� t� O O <br />b. Region D f <br />c. INDEX '{p [ t Q <br />d. PCA O O <br />e. MPC 0 0 61 317 <br />f. SITE / ,n n F1 / t n <br />c. Address /�700 eo SLU e0 Fs. Cs,-.Lwo I g. County <br />Number Street city Zip <br />11. SAMPLES <br />Field Information <br />15. CH F CUSTODY <br />ignaturo a Title Iru;tusive Datea <br />b. 71 v �p 1/11 rte. / <br />Signature Name/Title Inclusive Dates <br />C. / / - / <br />Signature Name/Title Inclusive Dates <br />d. <br />Signature Name/Title Inclusive Dates <br />16. LAB REMARKS: <br />F <br />I <br />E <br />L <br />DTSC 1116 (REV. 1/94) - Original -Lab a Duplicate -File is Triplicate -Inspector NILY (HMW <br />(Formerly DHS 8002) <br />Sample <br />Container <br />a. ID b. Collector's No. <br />c. Lab No. d. Type <br />e. Type f. Size <br />B <br />C <br />_ <br />D <br />_ <br />E <br />_ <br />F <br />G <br />H <br />12. ANALYSIS REQUESTED <br />f. ❑ VOA -8020 <br />1. ❑ Flash _ <br />Point <br />a. P PH <br />g. ❑ VOA-H/S <br />M. ❑ C1 -Pes- <br />ticides <br />b. Gg4etal <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. E?VrOA-8010 <br />Diesel/ <br />k. 0 Gasoline <br />q; <br />13. SPECIAL REMARKS: <br />Field Information <br />15. CH F CUSTODY <br />ignaturo a Title Iru;tusive Datea <br />b. 71 v �p 1/11 rte. / <br />Signature Name/Title Inclusive Dates <br />C. / / - / <br />Signature Name/Title Inclusive Dates <br />d. <br />Signature Name/Title Inclusive Dates <br />16. LAB REMARKS: <br />F <br />I <br />E <br />L <br />DTSC 1116 (REV. 1/94) - Original -Lab a Duplicate -File is Triplicate -Inspector NILY (HMW <br />(Formerly DHS 8002) <br />