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State of California-Health and Welfare Agency% % Department of Health Services <br /> Hazardous Materials Laboratory <br /> HAZARDOUS MATERIALS 1. Authorization Number HML No. 2. Page <br /> SAMPLE ANALYSIS REQUEST 1 1 i I ITo of <br /> 3. Requestor : 4. Phone ( ) 5. Priority ❑ <br /> Address(To Receive Results): a. Authorized by <br /> 6. Date Sampled 7. Time Sampled Hours 8. Codes (fill in all applicable codes) <br /> 9.Activity: ❑SEB ❑SMB 1:1 FPB ❑ATD Cl PASD ❑Other <br /> a. STC <br /> b. Region <br /> 10.SAMPLING LOCATION c. TPC <br /> a. EPA ID No. d. INDEX <br /> b. Site e. PCA <br /> f. SITE <br /> c. Address g. County <br /> Number Street City Zip <br /> 11.SAMPLES <br /> Sample Container <br /> a. ID b. Collector's No. c. Lab No. d. Type e. Type f. Size g. Field Information <br /> A f-2(D 0 <br /> B <br /> C F <br /> D I <br /> E EL <br /> F D <br /> G <br /> H <br /> 12.ANALYSIS REQUESTED f . ❑ PCB k.❑ Ext. Org <br /> (Screening) <br /> a. ❑ pH g.❑ VOA-H/S i. ❑ Flash <br /> Point <br /> b.❑ Metal h. ❑ VOA-8240 m. ❑ <br /> Scan <br /> c.❑ Metals i. ❑ VOA-8260 n. ❑ <br /> (Spec) <br /> d.❑ W.E.T. j. ❑ SVO-8270 o.❑ <br /> 13.SUPPLEMENTAL ❑ ❑ Initials <br /> REQUESTS <br /> ❑ ❑ Date <br /> 14.CHAIN OF CUSTODY <br /> a. <br /> Signature Nsrr rr itic Invuaivc Detea <br /> b. <br /> Signature Namerritle 1nc1usivc Dates <br /> C. / / — / / <br /> Signature NarrwMd. Inclusive Dates <br /> d. / / - / / <br /> Signature Namc/ritic lndusivc Dates <br /> 15.SPECIAL REMARKS: <br /> 16.ASSIGNED TO: Date <br /> 17. LAB REMARKS: L <br /> A <br /> B <br /> DHS 8002(Rev 10/90) Original-Lab Duplicate-File Triplicate-Inspector NLY(HML) <br />