Laserfiche WebLink
` Department of Health Services <br />State of Cellfornla—Health and Welfare Agency <br />HAZARDOUS MATERIALS SAMPLE ANALYSIS REQUEST -7 L <br />HML No. 0 <br />PRIORITY To <br />(Explain) <br />PART I: FIELD SECTION <br />Collectory _"-u✓G.Q -' Date Sampled �� Z�' `� Time Hours <br />Activity: Enforcement ❑ ASP ❑ H.W. Property ❑ Super ❑ Other ❑ RCRA TP Code I <br />Region: ❑ SCERS-SAC 0 NCS -SAC ❑ NCS -FRESNO ❑ SCS -LA ❑ NCCS-BERK <br />LOCATION OF SAMPLING: EPA ID NO. <br />Nam <br />�, ✓ ���',�- Tel. No <br />S . <br />Address -� j street city Zip <br />Number <br />HML No. Collector's Type Of <br />(Lab Only) Sample No. Sample FIELD INFORMATION <br />C 1-7 -7L ool S nt <br />C I rot) —o3 <br />-- oaf <br />C �D i t pJ wi <br />Analysis Requested: <br />Ch of Custody: y� <br />:�� 1���v`J <br />1 Signature Title Inclusive Dates <br />Signage U Title Inclusive Dates <br />Signature <br />4. <br />Signature <br />5. <br />Signature <br />Special Remarks <br />Title <br />Title <br />Title <br />(e.g., duplicate sample given to company, etc.) <br />Inclusive Dates <br />Inclusive Dates <br />Inclusive Dates <br />FART II: LABORATORY SECTION I , <br />�-�D/,� <br />Received By �'1 �-� hu Title ! r <br />Sample Allocation: ❑ HML ❑ SCBL n El LBL ❑ Other <br />Analysis Required C l� ?Q 1 0 <br />'Indicate whether sample is sludge, soil, etc. <br />Oria.-Lab. Dup.-File Trip. -Inspector <br />Date G <br />Date <br />