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Sta,-� of Caluornia-Health and Welfare Agency Department of Health Services <br /> �40t(,,A L I Hazardous Materials Laboratory <br /> HAZARDOUS MATERIALS 1. Authorization Wumber HML No. 2. Page <br /> SAMPLE ANALYSIS REQUEST ,C y N 7 To / of / <br /> 3. Requestor : 4/A., 14 Z-ec' 4. Phone(911,) PSS- - 21,e Z 5. Priority <br /> Address(To Receive Results):��f�f G,eo,,404w [i a� ,5,«ti 3, S� c,4 7S3Z� a. Authorized by <br /> 6. Date Sampled 7.Time Sampled Hours 8. Codes (fill in all applicable codes) <br /> 9.Activity: Zi-KB ❑SMB Ej FPB .1 ATD `�PASD ZI Other a. STC <br /> b. Region <br /> 10. SAMPLING LOCATION C ((� fl j 3 b `� 9 c. TPC <br /> a. EPA ID No. d. INDEX <br /> b. Site L��� ?Wr T,4/ 7Ct-� e. PCA <br /> f. SITE <br /> C. Address Z/3 SOIt4 g. County <br /> Humber S i Ctty 7,P <br /> 11.SAMPLES <br /> Sample Container <br /> a. ID b. Collector's No. c. Lab No. d. Type e. Type f. Size g. Field Information <br /> A 1A L 1'►,Z `I 2 7? — ( S o 4.r1 0 5 5 -Jim , P, c e ,-tc, S <br /> L ti L)5 ' 7%7 S CIL"i - (a s y X7 Lt• D L4,5* F <br /> D I <br /> E EL <br /> F D <br /> G <br /> H <br /> 12.ANALYSIS REQUESTED f . ❑ PCB k.❑ Ext. Org <br /> (Screening) <br /> a. J pH g. ❑ VOA-H/S i.❑ Flash <br /> Point <br /> b.❑ Metal h.❑ VOA-8240 m. ® �w L 5�� •>>•$ <br /> Scan <br /> c.❑ Metals i.❑ VOA-8260 n. ❑ <br /> (Spec) <br /> d.❑ W.E.T. j. ❑ SVO-8270 0.❑ <br /> 13. SUPPLEMENTAL ❑ ❑ Initials <br /> REQUESTS <br /> ❑ ❑ Date <br /> 14- CHrUSTT 1C� �C v ��� 5 s ZZ <br /> a. C �,LT— <br /> sRn.n,.e x.me/rue tndusi�e D.m. <br /> b. <br /> 5ignamuc 1:.—InJc ,ndYa-Dn <br /> C. / / - / / <br /> signanue / \une/I'Jc IncJwi.e Daicc� p?�p-- <br /> d. <br /> sigiunvc N. /Tak l 'usi.c Due. <br /> 15. SIAL REMARKS: <br /> 16. ASSIGNED TO: Date <br /> 17. LAB REMARKS: L <br /> A <br /> _ B <br /> DHS 8002(Rev 10/90) Original-Lab Duplicate-File Triplicate-Inspector NLY;HML! <br />