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State of--alifornia-Health and Welfare Agen— Department of 'Healt7.Service <br /> HAZARDOUS MATEri,.ALS All applicable items HML No. 2:'P= <br /> SAMPLE-ANALYSIS REQUEST must be completed To �- ( =f <br /> 3. Collector/Address =. Phone _- PrSorit - + <br /> `t-1 1 —,::;y9 V a. ..,utho,rized by <br /> 6. Date Sampled 3�3 � 7. Time Sampled 'l Hours 3. Codes (fill in all applicable codes] <br /> 9. Activity. Enf. ;.. Sury a.STC <br /> � El Mit ❑ Permitting ❑ Ait Tech El <br /> /� �/ / _ b. Region <br /> 10. SAMPLING LOCATION t T !, V U b —] to CTID' <br /> a. EPA ID No. <br /> ! r— d. INDEX- <br /> b. Site ( 1�1�i I1)� 1�Sem f 1 — e. PCA <br /> c. Address 10" 32) I. SITE <br /> Number Street .City Zip �'_ g. County O '1 <br /> s 11. SAMPLES - <br /> — Container _ <br /> a. ID b.Collector's No. c•HML No. d. Type e._Type f. Size g..Field Information <br /> A. �3A,,i✓303�01 J �r�r`(? _ ��24r <t��,o &l v c - <br /> B. a/TtjyD3- rst i D C� /LGA S r t C. <br /> D. <br /> E. <br /> F. <br /> G. <br /> H. <br /> ---- k. Ext.Org <br /> 12.ANALYSIS REQUESTED f. ❑ PCB (Screeng) <br /> a. ( pHi. E]Chlorinated <br /> t 9' ❑ VOA Pesticides <br /> b. Metal — h. PAH m. ❑ Pesticides <br /> Scan Ft t ►3 <br /> iC.❑Metals �raaxrs�• <br /> ;'Spec)., ._ i. ❑ Phenols r•.❑ <br /> j. ❑Carba- <br /> d.❑ W.E.T. mates c ❑ <br /> 13. CHAIN OF CUSTODY p <br /> a. Ali!Z48FT74 Al'" <br /> Signature Name/Title " 'Inclusive Datesb. <br /> " <br /> atu Name/ 'tle Inclusive Dates <br /> = <br /> Signature. _ Name/Title Inclusive D_-es _ <br /> d. s <br /> Signature Name/Title Inclusive D.—,es- <br /> 7 <br /> .es_ <br /> s <br /> 14. SPECIAL REMARKS-'---_.._. <br /> 15. RECEIVED BY '` ���—�� .'`r::•,' ":`-a.Title � \ - • b. Date `. <br /> 16. SAMPLE'ALLOCATION a. HML-Berkeley b. ❑ HML-SC c. ❑ AIHL d. ❑ Contract' '-b. Date <br /> 17. ANALYSIS REQUESTED <br /> OHS 8002(Rev 7/87) Original-Lab Duplicate-File Triplicate-Inspector NLY(HML) <br />