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State of California <br />alifornia EnvironmentalProtection <br />Department of Toxic Substances Control <br />ENVIRONMENTAL CHEMISTRY LA130RATORY <br />SAMPLE ANALYSIS REQUEST <br />1. Authorization Number <br />ECL No.: <br />To <br />Environmental <br />A I ZZ& <br />72 <br />Laboratory <br />2 Paga <br />1 of 1 <br />IOECO152 <br />3. Requestor:(to Redeive Resulu) a. Name: Dylan Clark <br />b. Address: -8600 Cal Center Drive <br />(w«i M.aban <br />4. Project Name (if applicable): <br />Sacramento, CA. 9 fe1y. an., ze) <br />5.TAT Level: 2 <br />— -- <br />c. Phone: (916) 2554909 I. n roq d. Fax: (916) 2556"6 (rr coda trap <br />a. Small: dclark @dtsc.ca.gov <br />6.Sampling Information: a. Daterrime Sampled: <br />b. Location: EPA ID No. <br />Site: Oakland Bag <br />Address: 635 Aurora <br />Stockton, CA _ <br />GPS -tat GPS -Long: <br />GPS -Alt: GPS -Depth: <br />02110/11 (MnVdd/yy) <br />1IAM-12 PM (#:## AM/PM) <br />cww m-.bw) <br />(o1y, a , zip) <br />_ _ <br />7. Codes tuba man drop da,e in, r N m a appiodq <br />a. Unit Est:RP-oalmr cdn al Irwaaap.aona <br />b. INDEX 4010 <br />c, PCA 35322 <br />d. MPC 404 OLA <br />e. SITE 91400848 <br />f. County 39–san Joaquin <br />8. Samples: <br />a.ID b. Colledoes No. c. ECL No. d. Matrix <br />f. Number of <br />e. Container Size containers <br />g. Preservative / Field Information <br />1 Oak81lI'DO fl Ink <br />4 oz dear glass jar 1 <br />Kept on tee, pure ink product <br />2 OakB2 azizzl Multiphasic <br />32 oz dear glass jar 1 <br />Kept on ice, plate developer <br />3 OskB3 7 "2 O8 <br />32 oz dear glass jar 1 <br />Kept on ice, used oil <br />4 Osk84 Multiphasic <br />32 oz dear glass jar 1 <br />Kept on ice. water based ink with al <br />5 <br />6 <br />9 <br />9. Ana ais Requested: Enter sample IDs and sample ID ranges separated by commas. For example, iJ, 5-7, 9 <br />F <br />a. Inorganic Analysis Samples) ID b. Organic Analysis <br />j Sample(s) ID <br />x <br />Metals Screening by XRF (XRF) 2, 3, 4 <br />Flash Point (1020A) <br />11,2,4 <br />E <br />L <br />D <br />- <br />Other Metals - <br />-- <br />c. TCLP Analysis <br />d. Other Analysis <br />a. Comments for Multiphasic Samp(aidAnslysfs Priority: <br />10. Analysis Objective: Waste Classification <br />11. Detection Limit Requirements: (Check ECL User's Manual to assure default DL is sufficient) <br />Need to test for waste classification. <br />12. Supplemental Requests: Enter sample IDs as described In Item 9 13. ECL Lab Remarks: <br />Desired Analysis j Samples) ID 8 <br />initials C <br />L <br />Date <br />L <br />a <br />14. Chain of Custody: <br />Name Title <br />j Signature <br />Indusive Dates of Custoov <br />a. Dylan Clark j H.S.S. <br />9 //&/it to '2(tl 1, <br />b. <br />to _ <br />e. <br />to <br />c <br />d. <br />to <br />0 <br />c <br />e. <br />to <br />_ <br />t <br />to <br />g- <br />to <br />ECL02 (REV 07/10) Make Photocopies for Your File <br />