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Stato of California—Health araC. walfere i goncy <br /> Department of Health Se vices <br /> PP,IORI?•YHAZA )US MATERIALS SAMPLE ANALYSIS RE :ST <br /> �� ., • <br /> 1 //�� H�1L No- <br /> (Explain) <br /> Lc-fl fGe Y�1eh1 ��� �S �t��Cl`C0.fi to r1 To <br /> PART I: FIELD SECTION Com' i <br /> Collector !^oL i <br /> Date Sampled a 3 Gh ��t8� Time _�.�_ Hours � <br /> I <br /> Activity: Enforcement ASP ❑ H.W. Property ❑ Super ❑ Other ❑ RCRA TP Code <br /> i <br /> Region: ❑ SCERS—SAC )91 NCS—SAC ❑ NCS—FRESNO ❑ SCS—LA ❑ NCCS—BERK <br /> LOCATION OF SAMPLING: ` r EPA ID NO. _CI RI PICOi ri�I--IJ�C--(I <br /> Name Q���, l_ \ n�CC G1 I T"G.nS 1 c✓ Tel. No (2 09) bL- 3 S 5 y <br /> Address 1n� �• �l VU-(-Ol t S+0 C- i <br /> Number Street j City Zip <br /> HML No. Collector's Type Of <br /> (Lab Only) Sample No. Sample' FIELD INFORMATION <br /> -7zM03�- 03 L5 aC,� slud4P W'l � uard S s�dQ <br /> I: <br /> Analysis Requested: T-; 1 ►^.•.9.�1 <br /> L j <br /> G — 01 a v-,c� <br /> 1-hain of 4tody: <br /> -71) a r <br /> ' gnat <br /> 2u� � Title � C7'W InUuslve Datfis <br /> _ o r <br /> SI na Tl' ` Inclusive Date l <br /> Signature Title Inclusive Dates <br /> 4 <br /> Signature Title nclusivt Dates <br /> Signature Tule Inclusive Dates <br /> Soecial Remarks <br /> (e.g-, ouplicate sample given to company,etc.) ; <br /> i - <br /> I <br /> 'ART H: LABORATORY SECTION I <br /> Received By Title Date <br /> Sample Allocation: ❑ HML ❑ SCBL ❑ LEL Other Date <br /> Anzlysis Required <br /> i.. <br /> (.= <br /> 'Indicate whether sample is sludge,soil,etc. I i <br /> Orig.—Lab. Dup.—File Trip.—Inspector <br /> :)HS 8002 (1/86) I' <br />