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— 2 g c h e m t e c h = _ <br />+-- <br />F• - 0 4 <br />Sla"f Calaamla-Health and Welfare e y �p/,(� `- ID�✓'1� <br />II jA\_ Daparlm X services <br />% Hazardous Matcrl eboratcry <br />� „ / 2150&Pe2C"rkeley. CA 84704 <br />U t (J(�Fe IR <br />* „lao; <br />HAZARDOUS WASTE TESTING CERTIFICATION^F(wav�ICE/r <br />APPLICATION FOR CERTIFICATION OF HAZARDOUS WASTE TESTING LABORATORY) x <br />INSTRUCTIONS /" ` ( / —7-1<q <br />/< r f <br />I. This application consists of: Part A, Laboratory Information; Part B, Personnel Oualiflcatlons; Part <br />C, Test Categories; Part D, Ouallty Assurance; Part E, Instrumentation and Equipment; and Part F, <br />Other Pertinent Information, and Approval by Laboratory Owner or Representative, <br />2. Check the appropriate boxes In each Part and supply the Information requested. Please TYPE all <br />Information requested. <br />3. The applicant laboratory must Inform the Hazardous Materials Laboratory, Department of Health <br />Services any changes/updates to the Information provided by the applicant within thirty (30) days of <br />such changes. <br />4. Enclose the application fee of S h2LILtL• for certification or $ -C 6 7 for annual fee, unless <br />exempted. Make check payable to DSPA-RTMENT OF HEALTH SERVICES. No fee is required for <br />any laboratory operated by a state or focal government agency. (Health and Safety Code, Chapter <br />6.5, Division 20, Article &S, Section 25198.7 (c)). <br />5. Return the completed application and fee to: DEPARTMENT OF HEALTH SERVICES <br />ATTENTION: CASHIER <br />P,O.BOX 1525 <br />SACRAMENTO, CA 95807 <br />6. This application will be used for recertification as well as certifruation pursuant to Health and Safety <br />Code, Section 25198,3. <br />PRIVACY NOTIFICATION <br />The Information in Part B of this application Is requested by the State Department of Health Services In compliance with <br />Information Practice Act of 1977. The authority for maintaining the requested Information Is California Adminl3trative <br />Code, Title 22, Section 67605. This Information Is mandatory. Failure to provide all the necessary Information will be an <br />automatic denial of the application for certification of hazardous waste testing laboratory. The purpose of this Information <br />Is to vorlty the personnel qualification requirements for laboratory supervisor or director. This Information will not be <br />disclosed outside the Department of Health Services. For more Information or access to your records, contact the <br />Department of Health Sorvlcea, Hazardous Materials Laboratory, 2151 Berkeley Way, 8. r 4704, Tel, (415)540. <br />3003. <br />Laboratory Name: <br />Line Item Coda 6515 <br />LAB 1001 (Rev 12187) <br />For Accounting Use Only <br />Date Received <br />1ML/t" ')TIFICATION UNIT <br />w:. <br />4mS, oct(KEMY, CALIFORNIA <br />Amount Received <br />