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State of California-Health and Weltare Agency Department of Health Se <br /> HAZARDOUS MATERIALS All applicable items 1. HML No. 2. Page <br /> SAMPLE ANALYSIS REQUEST must be Completed To ofc <br /> 3. Collector/Address ,(,In 0. a. Phone (0 30l Igva <br /> ) S ® -T <br /> Cro d0/] / (9 -�� s. Pndnty JlL1v1 <br /> S� a.Authorized by I�- r'1 ass, L,be <br /> 6. Date Sampled �� (� 7. Time Sampled Hours 8. Codes (fill in all applicable Codes) <br /> 9. Activity ❑ Ent ❑ Sury C1 Site Mit . Permitting ❑ Ail Tech ❑ Other a.STC ;77 <br /> 0 iI O <br /> `/ b. Region 'T <br /> 10.SAMPLING LOCATION ICIll 4 7 c.TPC <br /> �p <br /> a. EPA ID No. / O <br /> b. Site <br /> �Iec 1�e Qn@ /L �� d. INDEX <br /> // / / �i '1 e. PCA D <br /> c. Address� �Q E, / nd F,IJC.& 7 J � I. SITE <br /> Numoer Street City Zio g. County <br /> 11.SAMPLES <br /> Container <br /> a. 10 b.Collector's No. c.HML No. d. Type e.Type I. Size g. Field Information <br /> A. OLD RC-1 F%4�Q 0 r, 7�)�.r <br /> C. 'GC <br /> D. <br /> E. 6L-D-90-S )- �:4Q+ I <br /> F. Oi-D- Lfp <br /> G. <br /> it.L-I Ext. Org <br /> 12.ANALYSIS REQUESTED I. ❑ PCB (Screeng) <br /> a. ❑ pH c. ❑ VOA I. ❑Chlorinated <br /> Pesticides <br /> b. ❑Metal h PAH m. ❑Organo-P <br /> Scan Pesticides <br /> c.NMetals <br /> ISpec) i. ❑ Phenols n. ❑ <br /> d. ❑ W.E.T. L ❑Carba- <br /> mates 0.❑ <br /> 13. CHAIN Or CUSTODY <br /> / Sign tune / N Jt� pinclusive Dates - <br /> ��CCU�C` �r`u l( runt / L <br /> Signature Name/Title I inclusive Dates <br /> C. <br /> Signature Name/Title - '- Inclusive Dates <br /> Signature NameiTide Inclusvve Dates <br /> 14. SPECIAL REMARKS <br /> 15. RECEIVED BY , - -- a. Title /"Y'f l�1y- •- b. Date ✓ O - <br /> 16. SAMPLE ALLOCATION a. _ HML-Berkelev b. _ HML-SC C. [ AIHL ,. _ Contract S. Date <br /> 7. ANALYSIS RECUESTED �y% " � �� /�•' <br />