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t — <br />} <br />Stats of California -California Environmental Protection Agency Control <br />as <br />HAZARDOUS MATERIALS <br />1. Auth Nu <br />SAMPLE ANALYSIS REQUEST H NA M 2-T9 (rs 6a> t <br />-3. Requester. A I AM J 4. Phone (9«► )255" -310 z7 M. Pri ,...1 <br />Address (To Receive Resultswo/s Czo,,14,c✓ri.S�.,t -3; S►. U► Sb Z Z a. <br />6. Date Sampled 7. Time Sampled Hours S. Codw (fill irr <br />a. STC <br />9. Activity: SEB ❑ SMB <br />❑ FPB C] FMB ❑ HQ <br />❑ OTHER <br />• <br />b. Region ® <br />10. SAMPLING LOCATION <br />c. INDEX <br />a. EPA ID No. <br />d. PCA ''b <br />D <br />' b. Site _ �.... eint +L/t�tl ��1-oc�uGS <br />e. MPC 0 <br />0101317 <br />f. SITE.6_000/ <br />' C. Address �y SeV eL-+ <br />g. County <br />Nuincer <br />Suva city <br />zip <br />i 11.. SAMPLES <br />'i <br />Sample <br />Container <br />a. ID b. Collector's No. <br />c. Lab No. d. Type <br />e. Type f. Size <br />Field Information <br />A <br />B <br />C <br />D <br />E <br />F <br />? G <br />i H <br />1 <br />12. ANALYSIS REQUESTED <br />f. ❑ VOA -8020 <br />1. ® Flash <br />Point <br />a- LIB 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. Z"OrOA-8010 <br />Diesel/ <br />k. ❑ Gasoline <br />q: ❑ <br />13. SPECIAL REMARKS: <br />y.. <br />15. CH F CUSTODY <br />' <br />a- <br />J�ro„at� <br />09 /11 <br />Inclusive Docs <br />/ <br />/ <br />Signature <br />Nrno/rita <br />Inclusive Doug <br />C. <br />Signature <br />/ <br />Na wVnde <br />/ - / <br />Incius" Oates <br />/ <br />d. <br />Signauw <br />/ <br />NacuVTift <br />/ - / <br />Inclusive Oates <br />/ <br />e 16- LAB REMARKS: <br />11 <br />OTSC 1116 (REV. 1/941 Original -Lab • Duplicate -File is Triplicate-) NLY (MMU <br />(Forma riv OHS 8002) - <br />