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AM <br /> - ,�=Health z_, Welfare Agency pepartrnen.; of Health Se-- <br /> 4 ZARDOUS <br /> e-.4ZARDQUS MATERIALS All applicable rrer�_ 1. HML no 2. pace <br /> .MPLE ANALYSIS REQUEST must be cornplerel To _0 �f <br /> ,p11SCfOr/Addre55 4, Phone { } _ <br /> 5. Priority <br /> a. Autroriz-- by <br /> I 6. Date Sampled zl7 �� 7_ Time Sampled �L'ours S. CodeS (fill in all applicable codes) <br /> ¢ - <br /> Activity ❑ ErtfSure Lr] Site Mit ❑ Permimng ❑ Ait Tech ❑ 4•--er a- STC 0 0 <br /> v b. Region <br /> 10, SAMPLING LOCATION c. TPC <br /> � yy 1 I j f a. EPA ID No. <br /> c. Site U_!� L� �� IJ�L�( CJ-s d. INDEX L% C <br /> l II e. PCA <br /> y �f <br /> A.ddre$s t. SITE <br /> 3t l I LL) t l�^c' �'� U <br /> i c_`�"� /` <br /> Number Street City 7_ip <br /> f <br /> 11. SAMPLES <br /> Container <br /> z_1D b.Collector's ti°c <br /> C.HML No, d, Type e.Type I, S .- _ Field Information <br /> A. C�,Ln C-Z Z4—0 1 -777;(.i � t�%1ti� .' r�• i I r,-4 <br /> B. Rau' �1 I,�, _�,• t, <br /> C' _I� f�L714- <br /> D ' �f�LU <br /> •'.i r' 1 <br /> P <br /> V- } <br /> F. <br /> G. L <br /> H. D <br /> R.❑ Ext. Oro <br /> $I 12. ANALYSIS REQUEST-D I. ❑ PCB (Screer-) <br /> t ❑ PF{ 1.1v Chlorinated <br /> g ❑ VOA Jt� <br /> Pesticides <br /> ML <br /> m. rrtOrcano-an t. ❑ PAH tals( ec) i' ❑ Phenols n. ❑ <br /> t ❑ W.E.T. 1 Carba- <br /> mates ;'� `� 0.❑ <br /> i 13. CHAIN OF CUSTODY <br /> 9a)S <br /> /r Signatc-= Name/Title Inclusive DP'Les <br /> amen/TTiitle F Inclusive Dates <br /> Signature Name/Title Inclusive paves <br /> signalu•= Name/Title <br /> Inclusive Ca;as <br /> i 1-, SPECIAL REMARKS <br /> RECEIVED BY a. Title �. 1� b. Cate <br /> IE. SAMPLE ALLOCATIOrl. a. HML-Berkeley b, ❑ HML-SC c. ❑ AIH_ d. ❑ Contract b. Date <br /> 1; ANALYSIS REOUFSTED � �� o ��_ C'" L <br /> a <br /> t <br /> )rid ,Clb? Y - �i.t!".) �fl 'il�i-i_at7 ♦ G <br /> t• NLY ff-IIv1L! <br />