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1 <br /> � � '7epartrnent of Toxic Substances Control - <br /> -Sfte of Califomia �,/ Hazardous Materials Laboratories <br /> .talifomia Environmental Protection A en <br /> HAZARDOUS MATERIALS 1.Authorization Number HML No. 008/ 2.Pa8 e <br /> 62 <br /> SAMPLE ANALYSIS REQUEST N IL/ U 6 O To A d ,7O of <br /> 3.R_QUESTOR L'O Y� �74.Phone (5-fp)Sf(p - 7. TAT Level: (Checkone) <br /> z^ IRESS (To Re:zi/tie/Results) �-SG <br /> S.FAX p (sjo)s -3Sy/ <br /> [" ,4 951710 '1 2 3 4 <br /> UnH CNeis Synature _ <br /> B.DATE SAMPLED: S.Codes (fill in all applicable des) _ <br /> 111.ACTIVITY:(B SCD ❑ SRPD ❑CIB ❑SMB ❑FPB ' ❑SPPT ❑ Others a.Office d z <br /> 11.SAMPLING LOCATION b.INDEX 3E 0 <br /> a EPA ID/No. a PCA 6 2 <br /> b. Site We AIle <br /> nn'4, L 4 yy/Cl S el L L d.MPC - <br /> c. Addiess /POI fL/ - �T /•C� T OL�ie.SITE p <br /> Number - Street City 7JPj7S247/L County ✓Q F .. - . <br /> 12.SAMPLES: Samole Container <br /> a.ID b.Collectors No. c HML No. d.Type ` ee.Twe f.S"¢e .Field Information <br /> A /Yf c AO 008/9 Sfel / <br /> C <br /> D, <br /> Fe <br /> 13.ANALYSIS REO.UEST'EDr.., desired anal 's and enfer f.Os irom f 2.a. ' <br /> INORGANIC'ANALYSIS Sample(s) ID ` ORGANIC ANALYSIS Samole s 10 <br /> oH 4 , A ( CL-Pesticides 8081 <br /> stats Scan (6010) 41f OP-Pestlddes,.(8141)' <br /> Metal(s)SpecifiPC' PCBs (808 , <br /> WET G R O 80158 .. <br /> CYa <br /> vides D R O 1 Motor:Oil I Both (arae one) <br /> dhers,,Sots;, n-Hexane.Extractables 1664 ' <br /> others,,viae yr Flash Point (1020). <br /> TCLP Analysis' I� VOCs Including BTEX 8260 <br /> on V amecessa do Tcu, orates) VOCs-LO Level (5035) - <br /> Metals VOCs-Hl Level 5035 <br /> Mercury SVOCs 8270 <br /> Volatiles PAHs 270 i <br /> Semivolatiles <br /> others wdte in others,write in) <br /> 14.ANALYSIS OBJECTIVE: Waste Ctaractbrizati". Treatment5t.Wards ' <br /> (Check a bar) ng.H.b Standards (applies to DW%*) Others. - (tooted lab supervisors&si) . <br /> 15.DETECTION LIMIT REQUIREMENTS: <br /> (s a abrown aM aJnrdalaal <br /> 16.SUPPLEMENTAL Initials <br /> REQUESTS Date <br /> 17.LAB REMARKS: <br /> 18.CHAIN OF CUSTODY-. <br /> z t/s5 i // os .to <br /> rwq, �l 7��n n ! I121 to rI iia <br /> to 10 <br /> d <br /> to , I L IE <br /> Sionature/st <br /> Name(s) /Titfe/sl Inclusive Dates ofCustod �^ J <br />