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ate of fog^.la—Health and N.'elfa re Ageflcy Department of Health Services <br /> ' HAZARDIA MATERIALS SAMPLE ANALYSIS REQUO <br /> c �I <br /> ,IORITY= HMLNo.�? <br /> Explain) _ To <br /> RTI: FIELD SECTION <br /> (lector=1 L U� ` r JL Date Sampled_ �f Time / C Hours <br /> tivity: ❑ Enforcements ❑ H.W. Property ❑ Super ❑ Other <br /> ,COF ATION <br /> Name � �� W r n <br /> ++ `` �y Tel. No2-01 <br /> Address s� N- S.:•,c`ca,lrlh ( ci s—Lo S <br /> Number Street City Zip <br /> HML No. Collector's Type Of <br /> Lab Only) Sample No. Sample' FIELD INFORMATION <br /> W/L.565 ` 114 1- —e- 2- - IV:1� L;11e ftz Sd', e Ste_ 4 <br /> t <`7c✓r r` rp..:.< .tit a r SY" �� ..y�r c . <br /> :+..!sf: . <br /> ff lc ii-a So,,a Set .9 <br /> alysis Requested: 11'fx rL V& r)L44 .�y �77. (��7 re a.'.t- 'u tt't At S 0, 0 it c <br /> n <br /> iin of Custody• <br /> Title Inclusive Dates / 1 <br /> sh <br /> sign to Titled r ' nclusive Dares <br /> Signature Title Inclusive Dates <br /> Signature {� Title Inclusive Dates <br /> Bial Remarks Xe/eA.fed IF--,1e.-Ye,- knoat <br /> (e.g.,oupilcate sampl given to<ompan Y,a )�� <br /> .7T II: LABORATORY SECTION <br /> ( Z� <br /> eived By ��� � \c Title Date <br /> Iple Allocation: HML ❑ SCBL� ❑ LB_L ❑ Other '` n Date <br /> Clysis Required �T� (C_/^, � �. '�C c__ a �'� <br /> licate whether sample is sludge,soil,etc. Orig.—Lab. Dup.—File Trip.—Inspector <br /> 1002 (51 804 <br />