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Statc of California-California Environmental Prr pion Agency =t DepertttteM of Toxic Substances Control <br /> FOwerdous.Materiels Laboratory <br /> HAZARDOUS MATERIALS 1. Authorization Number-. = - fNMLN C�Z� 2. Page <br /> SAMPLE ANALYSIS REQUEST L Z = - TO4 (°� <br /> 3. Requester: M ''(�rt� 4. Phone 7flo 6. Priority Lersl <br /> Address(To Receive Results): Id U -0. a. Authorized by <br /> 6. Date Sampled I q j 7. Time Sampled 3 • OCHours 8. Codes(fill in all applicable codes) <br /> a. STC <br /> 9. Activity: SEB ❑ SMB ❑ FPB ❑ FMB ❑ HQ ❑ OTHER Q <br /> b. Region D <br /> 10. SAMPLING LOCATION d c. INDEX <br /> a. EPA ID No. d. PCA <br /> b. Site <br /> IL, e. MPC <br /> /1 f. SITE <br /> C. Address <br /> I I 1 �C�� C : g. County <br /> Number Street City ZED <br /> 11. SAMPLES <br /> Sample Container <br /> a. ID b. Collector's No. c. Lab No. d. Type e. Type f. Size g. Field Informat�on <br /> AWA 4rL44, <br /> B ?-�x+� �502gL �� F <br /> C 9.50`L-ria �� 1 <br /> D nOZa4 E <br /> E L <br /> D <br /> F <br /> G <br /> H <br /> 12. ANALYSIS REQUESTED f. ❑ VOA-8020 I. ❑ Flash <br /> nt <br /> a. ] pH g. ❑ VOA-H/S m.E] C1-Pes- <br /> ticides <br /> b.kMetal `r h. ❑ VOA-8240 n. ❑ OP-Pes- <br /> Scan ticides <br /> c. ❑ Metals i. ❑ VOA-8260 0. ❑ <br /> (Spec) <br /> d. ❑ W.E.T. 1• ❑ SVO-8270 P. ❑ <br /> Diesel/ <br /> e. ❑ VOA-8010 k. ❑ Gasoline q• ❑ <br /> 13. SPECIAL REMARKS. <br /> Initials <br /> > ; suP .iElwlrl�tAl~ <br /> :wwwRIEEI iU1wSTS <br /> ., . <br /> f3a2e <br /> 15. CH OF ST Y <br /> >� <br /> a• Na amt Inclusive Dates <br /> Signature _ _ 1 � <br /> b. n ura /Title Inclusive Dates <br /> alkz� rn <br /> C. Signature Name/TitleInclusive Dates <br /> d• Name/Title Inclusive Dates <br /> Signature <br /> 16. LAB REMARKS: L <br /> A <br /> B <br /> DTSC 1116(REV.1/94) Original-Lab • Duplicate-File • Triplicate-Inspector NLY(HML) <br /> (Formerly DHS 8002) <br />