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State of Cali fornia-Hea l(h and Welfare Agency Oepartmer.t of real:". Ser:,.es <br /> HAZARDOUS MATERIALS All applicable items HML No 2. Page <br /> SAMPLE ANALYSIS REQUEST must be completed To <br /> 3. Collector.rAddress s- Phore ('N41 731-•lfA-; 5, nt• <br /> p., <br /> Fri A.•/rT o y <br /> Y,//47COtJa�' -5w" To CA Ia.Autnorized by <br /> 6 Date S.aammp!ecl< 1,210 7/91 7. Time Sampled /.S J Hours 8. Codes )fill in all app ficable codes) <br /> t•,+5� ?r "�.iL:, ; _ 'a. STC O <br /> 9 Activity ' Ent,•, s Su" ❑ Site Mit Ll Permitting -:3A-1 Tech [I Other e) O -r el S O <br /> aRP''iPir iCItic4VY b: Region 'r <br /> 10MPLING O�C�AT ON- !L C t ry N c. TPC <br /> :SA <br /> A <br /> p ..,t.� a. EPA 10 No: <br /> b. Site �.r.': �/C/ � d. INDEX 0 <br /> /w e. PCA y O o C7 <br /> ..� c ;/6 �7�•� //ct /l.- ��f- I. SITE <br /> c. Ad.. ­­c �, ;/ LL, Lb.M /�..JJO <br /> Niimeery;� Street city Zio Count { <br /> . g Y o 3 9 <br /> _ i <br /> 1L SAMP ESS, - <br /> ce x Container L { <br /> a.19. b.Collector's No. C.HML No. d. Type e.Type I. Size , g.Field Information t <br /> . I } <br /> JJD207- .901 <br /> 7c: LV3 t7 Ci Ln _ I <br /> JF ice? dor! C S C, <br /> TF lac? IA. � �� <br /> 7 TFizo; a a1C C s r C 11,t2 r _j <br /> F: � <br /> G. <br /> H. J <br /> kL Ext. Org - ! <br /> 12.ANALYSIS REQUESTED I. ❑ PCB (Screeng) <br /> a•0:,.,pH. G { % g. C] VOA t. ❑Chlorinated <br /> Pesti <br /> b.❑Metal m. ❑Organo-P <br /> Scan - h. PAH Pesticides 1 <br /> c.®Metals - <br /> (Spec) f� b' �, •�_ F F t. ❑ Phenols n.❑ <br /> Carba <br /> d.C3W.E.T. I ❑mates o.❑ i <br /> 13. CH OF CUST00 <br /> 42 <br /> - Sig Jyare Na' rTd!e 1 Inclusive Dates{ <br /> b. <br /> �gn u e \ ' , NaM Tit e 1 - Inclusive Dates <br /> C. 1 \VIIWunZPAA <br /> Signalure Name/Tille Inclusive Dates <br /> d. - i 1 <br /> Signatu.e Vame%T;:!e Inclusive Dates j <br /> 14. SPECIAL REMARKS <br /> 16. RECEIVED 8Y �.�� , a. Title � �� b. Date <br /> 16. SAMPLE ALLOCATION a. HML-Berkeley b. ❑ HML-SC C. ❑ AIHL d. ❑ Contract b. Dale I <br /> 17. ANALYSIS REQUESTED v�' r-�••'�-�� C`-'c {��� <br /> R <br /> i <br />