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..� <br /> � __-- -' _ �- ---• -. �� �� Department of Health Sarvlce <br /> I California-Health and Welfare Agency �) f <br /> State <br /> o E ANALI <br /> HAZAP,DOUS MATERIALS SAMPLE REQUEST HML No bb <br /> A r —7 <br /> t� PRIORITY lT [�� <br /> (Explain) — <br /> 4. PART I: FIELD SECTION — l� <br /> Date Sampled o23l� —Time Hou <br /> Collector <br /> Enforcement ❑ ASP ❑ H.W. Property ❑ Super ❑ Other ❑ RCRA TP Code <br /> Activity: ❑ SCS—LA ❑ NCCS—EERi, <br /> —SAC NCS-SAC <br /> Region: ❑ SCERS ❑ NCS—FRESNO EPA ID NO. <br /> LOCATION OF SAMPLING: C Tel. No <br /> Name <br /> Address — Number street J <br /> HML No. Collector's Type Of FIELD INFORMATION <br /> (Lab Only) Sample No. Sample* on <br /> _ <br /> Ana is Requested: \�� <br /> rF <br /> ------------- <br /> Chair o Custody: a.A 19 <br /> I sive Dates <br /> + <br /> i <br /> /Signature Title <br /> Inclusive Dates <br /> I 2 T le`C _ <br /> i a .— <br /> "1 Inclusive Dates <br /> 3 4 Title _ <br /> -Signature' <br /> Inclusive Dates <br /> 4 T Itle <br /> signature <br /> Inclusive Dates <br /> Title <br /> signature <br /> Special Remarks (e.5 , euDll�te sampie give-,to company,etc.) <br /> PART II: LABORATO Y SECTION r t ti c <br /> :J, <br /> Date <br /> Jm�.i.• I F <br /> ?k Date <br /> ReceivedBy ❑ LgL CDOther. <br /> 'r � Sample Allocation: ❑ HML <br /> s a'� <br /> vC <br /> Analysis Required <br /> "Indicate whether sample soil,etc. Orig.—Lab. Dup.—File Trip.-inspector <br /> le is sludge <br />