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State of CaIif..n He th and Weifare Agency `� nepartment of Health Semcea <br /> REGION I OFFICIAL SAMPLE RECEIPT REGION s <br /> 10151 Croydon Way 1405 N.San Fernando Blvd. <br /> Sacramento, CA 95827 Burbank,CA 91504 <br /> (916)855-7700 TOXIC SUBSTANCES CONTROL PROGRAM (818)567-3000 <br /> REGION 2 REGION 4 <br /> 700 Heinz Avenue,Suite 200 245 W. Broadway.Suite 305 <br /> Berkeley,CA 94710.2737 Long Beach, CA 90802 <br /> (415)540-2122 (2131590-4868 <br /> PYrm Name Date <br /> ohsk <br /> Addrcea � City ZIP Cada <br /> Perwn InteMe �� POMBon <br /> 15 HAJ io v iV <br /> The Items listed below were collected as official samples on this date as authorized by Section 66328, <br /> California Code of Regulations, Title 22. <br /> Quantity Unit Size Material In Number <br /> `6- c)`Z f& Ak S(JPK 7 <br /> r <br /> v <br /> z _ <br /> / S <br /> Receipt acknowledged by: <br /> the, <br /> By <br /> 9lgnahre A M uo dAgent <br /> EH 2081 911 <br />