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$State of California-Health and Welfare Agency Department of Health Services <br /> s'HAZARDOUS MATERIALS - All applicable items 1. HML No. 2. Page <br /> SAMPLE ANALYSIS' REQUEST must be completed To �— ( of <br /> 3. Collector/Address 4. Phone ( ) _ <br /> l.�'�r l n - 5. Priority- <br /> ��- _ 4_I _ a. Authorized by. <br /> 6. Date Sampled 313 7. Time Sampled, Hours 8 Codes(fill;in all_applicable Codes) <br /> r a. STC, <br /> 9. Activity..,,_,/� Enf:, Sury 0.Site Mit El Permitting I ❑,Ait Tech- ' ❑Onerv <br /> 1_N0101 <br /> r b. Region', <br /> 10.SAMPLING LOCATION A /� 77- -7 c:TPC; <br /> a. EPA ID No. <br /> b.Sited. INDEX::: LOL <br /> • ., (_11`�Y-�'tlYl ��se� m,F, <br /> i ' e:PCA . C1 <br /> c. Address 5, � C�'l: r C!c rf.SITE <br /> = Number Street City ; <br /> Zip g. County, O '1 <br /> 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. 030 01DO <br /> B. t D �- <br /> a -2 ` /aa't S r. <br /> D. <br /> E. F <br /> F - <br /> G. L <br /> H. D <br /> 12.ANALYSIS REQUESTED f. ❑ PCB k. E?qj 0 r <br /> `(Screeng) <br /> a. PH A t g• ❑ VOA _ I. ❑C�fT►teteei�.� <br /> �1 Pesticides <br /> b. Metal a . Organo-P <br /> Scan lT I h. PAH m ❑ Pesticides <br /> C.❑Metals t <br /> (SP?p)... ... i. ❑ Phenols n. ❑ <br /> j. Carba- ' <br /> d.E] W.E.T. ❑mates o.❑ <br /> 13.CHAIN OF CUSTODY <br /> �Uzr-� _ rrr 3 <br /> JSi nature Name/Title C`i Inclusive Dates <br /> b. <br /> atu fes. Name/ 'tle Inclusive Dates <br /> C. <br /> t -, �, J�► <br /> Signature Name/Title ,_rt' Inclusive Dates <br /> d. <br /> Signature Name/Title <br /> Inclusive Dates <br /> 14.SPECIAL REMARKS <br /> 15. RECEIVED BY � � ° a. Title � � \ b. Date <br /> 16. SAMPLE ALLOCATION a. HML-Berkeley b. ❑ HML-SC c. ❑ AIHL d. ❑ Contractb. Date <br /> 17. ANALYSIS REQUESTED '�� L <br /> A <br /> B <br /> DHS 8002 (Rev 7/87) Original-Lab • Duplicate-File • Trip cate-Inspector NLY(HML) <br />