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—S&w@-qqf Califomta-Health and Welfare Agency <br /> � 3ecartrnent of Health z,ervicus <br /> Hazaroous Matenats Laooratory <br /> HAZARDOUS MATERIALS 1.Authorization Number HML No. -7 r 2. Paqe <br /> SAMPLE ANALYSIS REQUESTC r. v To 7 � p of <br /> 3. Requestor: f Aki =Z� v 4.Phone(9/6)P5-- - 7 5. Priority <br /> Address(To Receive Results):/C 157 C,,?rcl w, (d.6 S.-6Lte 3 S r1ce4Mle.Lri as ; a.Authorized by <br /> 6. Date Sampled S"/�/ �, 7. Time Sampled Hours 8. Codes(fill in all applicable codes) t <br /> 9.Activity: R SEB Cl SMB ❑FPB C3ATD ❑PASD C]Other <br /> a. STC v <br /> y b. Region C i <br /> 10.SAMPLING LOCATIONc.TPC <br /> a. EPA ID No. d. INDEX 6 C u O <br /> b.Site ;dC 13 4 e. PCA3 C C <br /> I. SITE <br /> c.Address '1.'5'2-SW g. County C <br /> N.— Sam Gay zip <br /> 11.SAMPLES iI <br /> Sample Container <br /> a. ID b. Collector's No. c. Lab No. d.Type s. Type I.Size g. Field Information <br /> A Z37S—S-i- 1I-I <br /> B <br /> C F I, <br /> D 1 <br /> E E <br /> F L <br /> D <br /> G <br /> of H 1: <br /> 12.ANALYSIS REQUESTED f. ❑PCS k.❑ Ext. Crg I <br /> (Screening) <br /> a. 3L pH C ., g.❑ VOA-H/S i.❑ Flash <br /> Point <br /> b.® Metal CL- h.❑ VOA-8240 m: <br /> Scan S 1� <br /> c.❑ Metais i.❑ VOA-8260 n. ❑ <br /> (Spec) <br /> d.❑ W.E.T. !� neS�►ate j. ❑ SVO-8270 0.❑ <br /> i <br /> 13 SUPPLEMENTAL.... ❑. ❑ Initials, <br /> REQUESTS <br /> ❑: ❑ Date: <br /> I <br /> 14. CHAIN OF CUST�7 <br /> a. <br /> Sime Nunw uL tadv...D. <br /> C. - / / <br /> S;Pm.. Nmerrwk hrle n... <br /> d. / / - / / <br /> S; N.e.e/rwe Indw nee. <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 />