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'State of Calttornla—Health and Welfare Agency <br />Department of Health Services <br />- _ HAZARDOUS MATERIALS SAMPLE ANALYSIS REQUEST <br />PRIORITY�` <br />'1 <br />(Explain) r� I i��� t',�\c ,� y; <br />;� �_� Nui'�' <br />HML No \' �, <br />: , l To <br />C I`1R� <br />PART I: FIELD SECTION <br />Collector - <br />Date Sampled <br />t1 i I'� I i Time -^ �% (J Hours <br />Activity: ® Enforcement ❑ ASP ❑ H.W. Property <br />❑ Super ❑ <br />Other ❑ RCRA TP Code I <br />Region: ❑ SCERS—SAC E1 NCS—SAC ❑ NCS—FRESNO ❑ SCS—LA <br />❑ NCCS—BERK <br />(� <br />LOCATION OF SAMPLING: <br />EPA IDN 0. <br />Name <br />Tel. No <br />i <br />Address l `� i <br />i� -_. # <br />Number <br />Street <br />City Zip <br />HML No. Collector's Type Of <br />(`Lab Only) Sample No, Sample* <br />FIELD INFORMATION <br />\�= o� �—�-L �l r! <br />rli,C4 ar <br />c,.'t <br />fi116. 0 31; <br />- ��r ,A iAnc d s <br />n xc,Rei U3�� ('� 1 `J �+ <br />y S, -.r. <br />Analysis Requested: <br />moi, i 1 .� <br />1_:... l.� `, 1; c` <br />Chain of 9.istody: <br />f <br />-. <br />�—V., <br />� � � <l <br />� %�,. <br />•-•�:, •-n �� ��:' [,, � � <br />/ 1�.,_ :_c-- /{`-ham X� . , <br />1�,1 <br />';1 , !' <br />1 <br />Signature <br />Title <br />Inclusive Dates <br />^�-,Signatu1� <br />+ TIjb <br />'Inclusive Date <br />`Signature <br />Title <br />J Inclusive Dates <br />4. <br />Signature <br />5 <br />Title <br />_ <br />Inclusl <br />P I <br />rt',' �L <br />Signature <br />Title <br />_ <br />Inclusive Date# 11 <br />Special Remarks <br />(e.g., euplicate sar;pie given to company, etc.) <br />FART II: LASORt-TORY SECTION <br />.+ 19 EAE I H <br />Received By <br />t -�- <br />TitleDate <br />Sample Allocation,: ❑ HML ❑ SCBL <br />❑ LBL ❑i Other <br />Date <br />Analysis Required <br />*Indicate whether sample is sludge, soil, etc, <br />