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estate of California—Health and Welfare Agency - Department of Health Services <br />HAZARDOUS MATERIALS SAMPLE ANALYSIS REQUEST <br />PRIORITY= HML No. <br />(Explain) :� To <br />j <br />PART I: FIELD SECTION l <br />Collector Date Sampled fi; i=,-1 Time I �" >X Hours <br />Activity: ❑ Enforcement ❑ ASP ❑ H.W. Property ❑ Super ❑ Other ❑ RCRA TP Code 1 I 17 1-1 <br />Region: ❑ SCERS—SAC D NCS—SAC ❑ NCS—FRESNO ❑ SCS—LA <br />LOCATION OF SAMPLING: ( r <br />Name - J 4_ �_ , ,� e <br />Address <br />Number Street <br />HML No. Collector's Type Of <br />(Lab Only) Sample No. Sample* <br />O NCCS—BERK <br />EPA ID NO. <br />Tel. No��Cf;`,y( <br />— City <br />FIELD INFORMATION <br />Zip <br />1 ('� I �. <br />Analysis Requested: r- I' i i i 1, L \ r _ i I� P fz s.lr <br />Chain of Custody: <br />5 <br />Signature <br />Special Remarks <br />PART 1I: LABORATORY SECTION <br />Received By <br />Sample Allocation: <br />Analysis Required <br />❑ HML ❑ SCBL <br />Title <br />Inclusive Dates f l <br />T)tle}}.. 'r / Inclusive Dates / <br />F, )zy?I f) S ! J —) !tel ; ! �i � _ <br />Title / ' Inclusive Dates <br />Title <br />Title <br />(e.g., duplicate sample given to company, etc.) <br />Inclusive Dates <br />Inclusive Dates <br />_Title `)I'� I' Date <� <br />❑ LBL ❑ Other Date <br />WT <br />*Indicate whether sample is sludge, soil, etc. CNViKtVry -.ti l AL HEALTH <br />Oria.—Lab. Duo.—Fila T.ep—lnepa�+n. <br />I GG;,QI'i l4Fpulr FC <br />Signature <br />�- <br />Signature <br />3. <br />Signature <br />4. <br />Signature <br />5 <br />Signature <br />Special Remarks <br />PART 1I: LABORATORY SECTION <br />Received By <br />Sample Allocation: <br />Analysis Required <br />❑ HML ❑ SCBL <br />Title <br />Inclusive Dates f l <br />T)tle}}.. 'r / Inclusive Dates / <br />F, )zy?I f) S ! J —) !tel ; ! �i � _ <br />Title / ' Inclusive Dates <br />Title <br />Title <br />(e.g., duplicate sample given to company, etc.) <br />Inclusive Dates <br />Inclusive Dates <br />_Title `)I'� I' Date <� <br />❑ LBL ❑ Other Date <br />WT <br />*Indicate whether sample is sludge, soil, etc. CNViKtVry -.ti l AL HEALTH <br />Oria.—Lab. Duo.—Fila T.ep—lnepa�+n. <br />I GG;,QI'i l4Fpulr FC <br />