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State of czlifornia—Health and Welfare Agency Department of Health Services <br />HAZARDOUS MATERIALS SAMPLE ANALYSIS REQUEST C /�U <br />PRIORITY � HML No. <br />To <br />(Explain) <br />PART I: FIELD SECTION r <br />Collector T:> ' L, /`-o It ���—a Date Sampled � ` a —7 �d -7 Time Hours <br />Activity: P Enforcement ❑ ASP ❑ H.W. Property ❑ Super ❑ Other ❑ RCRA TP Code I <br />Region: ❑ SCERS—SAC NCS—SAC O NCS—FRESNO ❑ SCS—LA ❑ NCCS—BERK <br />LOCATION OF S,AQMPLING: nn EPA ID N0. <br />Name <br />/'). ­70 <br />TCt� 41� Tel. <br />Address 3 ( & --s.. u Dp 's, _4z" <br />Number Street <br />HML No. Collector's <br />(Lab Only) Sample No. <br />G i S/OS '-74-0 03: -ol <br />C r ,-y14 <br />C /S o4A <br />Analysis Requested: <br />Type Of <br />Sample' <br />SU�Q <br />Ch, of Custody: ( ��Y <br />o J �� �� ��•,�� <br />Signature <br />2_ i <br />signature 0 <br />3. <br />Signature <br />4. <br />Signature <br />5. <br />Signature <br />Special Remarks <br />h 7 <br />Title <br />Title <br />Title <br />Title <br />Title <br />IM <br />ty <br />FIELD INFORMATION <br />(e.s., duplicate sample given to company, etc.) <br />Inclusive Dates <br />Inclusive Dates <br />Inclusive Dates <br />Inclusive Dates <br />Inclusive Dates <br />PART II: LABORATORY SECTION <br />Receive <br />Date <br />Sample Allocation: <br />ED HML <br />[ISCBL ElLBL D Other <br />Date <br />Analysis Required <br />/= /" <br />��L) / C <br />`Indicate whether sample is sludge, soil, etc. <br />Orig.—Lab. Dup.—File Trip.—Inspector <br />