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State,of California-Callfornis Environmental Protection Agency 01 - 11 oilkTb+tiaSUNKNrssscontrol <br /> �a <br /> HAZARDOUS MATERIALS t. Authorization.Number !� 91:� ��_ :Z`PaIw, <br /> SAMPLE ANALYSIS REQUEST <br /> (� 3: Requester: M bf- 4. Phone(.I/,,)Z6"5, —3laZ(o Priorft Lsbjeft�:Wa JL ..� ;.. <br /> C Address(To Receive Resultsl: ld o U U a. Authorhmmi6pt <br /> B. Date SampledZ j 7. Time Sampled 3 • 00Hours 8. Codes(fill imall applicable codes))- <br /> & <br /> a.STC <br /> 9. Activity: SEB ❑ SMB ❑ FPB ❑ FMB ❑ HQ ❑ OTHER <br /> b. Region D <br /> 10. SAMPLING LOCATION 11 c.INDEX <br /> a. EPA ID No. d. PCA � <br /> b. Site <br /> e. MPC <br /> f. SITE <br /> g. County <br /> C. Address ` <br /> Number Street City Zig <br /> 11. SAMPLES <br /> Sample Container <br /> a. ID b. Collector's No. c. Lab No. d. Type e. Type f. Size 9. Field Information <br /> A <br /> B ��1-tx� `L5OZg2. ^� F <br /> C <4 1 <br /> �O-Lq 4 f E <br /> E D <br /> F <br /> G <br /> H <br /> 12. ANALYSIS REQUESTED f. ❑ VOA-8020 1. ❑ Flash <br /> Point <br /> a.�K pH g. ❑ VOA-H/S M. C1-Pes- <br /> ticides <br /> b.� ticides <br /> Metal `'�' h. ❑ VOA-8240 n. ❑ OP-Pes- <br /> Scan <br /> c. ❑ Metals i. ❑ VOA-8260 0• ❑ <br /> (Spec) <br /> d. ❑ W.E.T. j. ❑ SVO-8270 P. ❑ <br /> Diesel/ <br /> e. ❑ VOA-8010 k. ❑ Gasoline Q ❑ <br /> 13. SPECIAL REMARKS: <br /> - 'f4k S�P�.EMIri�TRly `�,� �tfa� <br /> s <br /> x � <br /> 15. CH OF ST Y / L <br /> T Indueive Oates <br /> a. Signature � —Naa•/Tit <br /> b. /Til^lsy�{��/� I req Inctustve Dates <br /> i n ureCA � -`J ' it V t I/ a\_ c,' <br /> C• Name/Title T— `(,/'�� Inclusive Oates <br /> Signature <br /> a d. Signature Name/Title Inclusive Dates <br /> 16. LAB REMARKS: L <br /> A <br /> B <br /> DISC 1116(REV. 1/94) original-lab • Duplicate-File • ct <br /> Triplicate-Inspeor NLY(HML) <br /> (Formerly OHS 8002) <br />