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State of Calif omia-Health and Welfare Agency Department of Health Services <br /> Hazardous Matenals Laboratory <br /> HAZARDOUS MATERIALS 1. Authorization Number HML No. 2. Page <br /> SAMPLE ANALYSIS REQUEST j Ic— I O I T7 To of 1 <br /> 3. Requestor : kAti 7' 4c) 4. Phone (q/d)BS.r 7 J'?_ 5. Priority <br /> Address(To Receive Results):10/5/ C&vlj� U,o y 5,��"� 3 S ACt4b"4i.1i,1A 7,f*Z7 a. Authorized by <br /> 6. Date Sampled , -/// f/ 7.Time Sampled Hours 8. Codes (fill in all applicable codes) <br /> 9.Activity: N SEB 0 SMB O FPB O ATD O PASD ❑Other <br /> a. STC in � v <br /> b. Region O <br /> 10.SAMPLING LOCATION c.TPC <br /> a. EPA ID No. d. INDEX (, D �( v <br /> b.Site Qk t Lk R 4 e. PCA 3 Z p o <br /> f.SITE <br /> c. Address ),32570 C, ,% e� IZ S-toc12_4,'\ g. County . 017 <br /> Nunimi svew Gry 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 z3zS- -I k 7-S,06, wAa-te. <br /> B <br /> C F <br /> D I <br /> E <br /> E <br /> L <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. [& 'TCL Q- U 0 p4�1 qtr <br /> Scan <br /> c.❑ Metals i.❑ VOA-8260 n. ❑ <br /> (Spec) <br /> d.❑ W.E.T. l� ne�'t a j. ❑ SVO-8270 0.❑ <br /> 13:'SUPPLEMENTAL ❑ ❑ Initials <br /> REQUESTS <br /> ❑ ❑ Date <br /> 14.CHAT F CUT�QDY <br /> a. h— Z2 <br /> sigunue N 61c hxluai-Dasa <br /> b. <br /> sigaatmc Name/frtic Inrluaive Dads <br /> C. / / - / / <br /> si8uu NamrlCitic b,duaivc Daw <br /> d. / / - / / <br /> sw"_ NamrJl-itis Indusi—Dm <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 />