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' <br /> % <br /> .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 AIM I CC (� y To 1 v of ! <br /> 3. Requestor: 1)lAn 4. Phone(q/6)PSS -i 7 � Z 5. Priority <br /> Address(To Receive Results):/015/ S ACX4L..c" ,a 7,fbz7 a. Authorized by <br /> 6. Date Sampled _57/// 7/ 7.Time Sampled Hours 8. Codes (fill in all applicable codes) <br /> 9.Activity: SEB ❑SMB ❑FPB ❑ATD ❑PASD ❑Other a. STC r <br /> b. Region C <br /> 10. SAMPLING LOCATION G^ c. TPC <br /> a. EPA ID No. d. INDEX 6 G p <br /> b. Site QL,_t a<- 13 i� e. PCA 1 C C <br /> f. SITE <br /> c. Address '1..2 5 I✓ Count <br /> ' 9• Y p i <br /> N sic 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 -L37-5 I--1 AS� <br /> B 1 y,c n� <br /> C F <br /> D I <br /> G E <br /> L <br /> F D <br /> G <br /> H <br /> 12.ANALYSIS REQUESTED f. ❑ PC8 k.❑ Ext. Cq <br /> (Screening) <br /> a. [I pH Cl g. ❑ VOA-H/S i. ❑ Flash <br /> Point <br /> b.® Metal Olt- h.❑ VOA-8240 <br /> Scan 1� / <br /> c.❑ Metals i.❑ VOA-8260 n. ❑ ' —o <br /> (Spec) <br /> d. ❑ W.E.T. j. ❑ SVO-8270 0.[1 <br /> 13.SUPPLEMENTAL ❑ ❑ Initials <br /> REQUESTS <br /> ❑ ❑ Date <br /> 14. CHAIN OF CUSTODY P—_— <br /> a. <br /> S Nestle In ve D.ts <br /> b. �G -r� - Te�Qi�tinr��n ZS - <br /> s�+mee Ymgli it3e h.6-i-Dm <br /> C. / / - / / <br /> si�.00e N­=r.:ue h cl-i—Dien <br /> d. / / - / / <br /> Sigutme x.mrJt sue <br /> Id.—D. <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-Fle • Triplicate-Inspector NLY(HML) <br />