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Slate of Call forn!a—Health and Welfare Agene� - - :� Department of Health Services <br /> OFFICIAL SAMPLE RECEIPT <br /> HAZARDOUS MATERIALS MANAGEMENT SECTION <br /> 1449 Temple Street 744 P Street 2151 Berkeley Way <br /> Los Angeles, 90026 Sacramento, 95814 Berkeley 94704 <br /> (213) 620-2380 (916) 322.2337 (415) 843.7900 <br /> Date <br /> Firm Name <br /> Address City Zip Code <br /> ,/ e ��rH�oP 7/330 <br /> Person Interviewetl Position <br /> 2 �/1 DL(fl✓f r <br /> The items listed below were collected as official samples on this date as authorized by Section 66328, California Administrative Code,Title 22. <br /> Quantity Unit Size Material I.D. Number <br /> ;D JF/.z o 7- o6/ <br /> ?T -5-11,ell, <br /> /l2 <br /> w 77WCA/nFA T L <br /> Receipt acknowledged by <br /> By <br /> Signature Authorized Agent <br /> EH 206(11/79) // 1oe94419 3 u xaiP-csr <br />