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.State of California-Health and Welfare Agent; Department of Health Sen <br /> HAZARDOUS MATERMLS All applicable items HML No. M 2. Page <br /> SAMPLE ANALYSIS REQUEST must be completed To of <br /> 3. Collector/Address L)nda- 4. Phone 1 Kl ) ��� ti <br /> /0/6-) Crayon G 8 y9S-77ES S. Pn uth LJ M 4 30 /5 sa <br /> /Oi <br /> 9s a 7 a. Authorized by 1 <br /> 7FSC �j/Y <br /> 6. Date Sampled S-� �p- yQ ,,,,,,......,,,/// 7. Time Sampled Hours 6. Codes (fill in all applicable Codes) <br /> 9. Activity ❑ Enf ❑ Sum ❑ Site Mit Up Permitting ❑ Ait Tech a. STC Q <br /> /" El <br /> b. Region <br /> 10.SAMPLING LOCATION 9 7 3 c.TPC <br /> y� a. EPA ID No. d. INDEX <br /> b. Site Jl� Q� 4a(X / �YAt <br /> e. PCA <br /> c. Address /-2,,2D ll'/r. pr ��. `n/�1 9��� y/ I. SITE <br /> Numoe2E Street City Zip Count <br /> 9 Y Q <br /> 11.SAMPLES <br /> Container <br /> 3. 10 b.Collector's No. C.HML No. d. Type e.Type I. Size g. Field Information <br /> A. <br /> C. <br /> E. <br /> F. <br /> ✓n i elf ✓YI <br /> G. <br /> H. <br /> 12. ANALYSIS REQUESTED I. ❑ PCB k.l❑ Ext. Org(Screeng) <br /> a. ❑ pH g. GI VOA I. -(Chlorinated <br /> Pesticides <br /> b. Metal <br /> In. ❑ PAH ^. Pesticide <br /> Scan � — Pesticides <br /> C. ru Metals. t <br /> Spec) nj II CT1aj z i n i. ❑ Phenols n. 1 <br /> d.❑ W.E.T. 1. ❑Carba- <br /> mates o.❑ <br /> 13. CHAIN OSC/UUST/ODY ,' / <br /> a. �� �"/ttC(L'�.{w,�I1�e�l^-'1 � ' `yLL�f� Lrr�C/�i�. �Jyt {1�7r�/��/� " <br /> o. at I�-L-/`i7`v 1 �`}-M l i\al l-Lt 11 t_. I �)cius�ve Dates <br /> Signature Name/Title I Inciusrve Oates <br /> Signature Name/Title Inauswe Dates <br /> a. / <br /> Signature Name/Title Incluswe Dates <br /> 14. SPECIAL REMARKS ,, q/� <br /> 15. RECEIVED BV.. 1 .a. Tide /"!'r'C;� b. Date /,0- <br /> 16. SAMPLE ALLOCATION.._. a. ❑ H _ ^erkeley bQ. —:- HML-SCC. ❑ AIHL =. _ Contract D. Date <br /> 17, ANALYSIS REOUESTED //'�. �J"`-'� /✓� <br /> :"S 002 -,7. 71 C., .. -. .. .... - .. <br />