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State of California-Health and Welfare Agency <br /> Department of Balt .Services <br /> HAZARDOUS MATER►_ .3 Ali applicable items H,�.,L No. 2.Pa== ' <br /> SAMPLE-ANALYSI�S� REQUEST• must be completed _ ' To' : <br /> `3- <br /> 3. Collector/Address <. Phone ( ) _ <br /> . Pnority ::0 <br /> D&4q �f / vis —} 9 a. ,authorized by <br /> 6. Date Sampled 3!3 l�) 7. Time Sampled .1 `.�. Hours 3..Codes (fill-in a_ll_applicable codes; <br /> 9. Activit cnf- ... Sury - a. STC <br /> Y � Site Mit Permitting ❑ Ait Tech` El O <br /> /\ n� {.� _ b. Region " <br /> 10.SAMPLING LOCATION rT X b O U -J C.TPC. - - <br /> a. EPA ID No. _ - <br /> b.Sited. INDEX- <br /> �nrri <br /> �y� �, (� e.PCA <br /> c. Address I s-i;' ��lJ, t V r Cis 'CC- f. SITE - <br /> I. Number Street .city Zip 9• County 0 -7 <br /> 11.SAMPLES : <br /> Container <br /> a. ID b.Collector's No. c•HML No. d. Type ; Dee Type f. Size g:Field Informaiion - <br /> A. <br /> Y2 6cr <br /> 112, A <br /> C. <br /> D. <br /> E. F <br /> I <br /> F. E <br /> G. L <br /> H. D <br /> k. Ext.Org <br /> 12.ANALYSIS REQUESTED ' f. ElPCB (Soreeng) {� ` <br /> a. pH dQ g, ❑ VOA l• ❑Chlorinated <br /> ,�;�>■ Pesticides <br /> b. (Metal m. Organo-P <br /> Scan FT I h. El PAH ❑ Pesticides <br /> C. Metals <br /> (Spec).' _ i. ❑ Phenols r,. ❑ <br /> d.❑ W.E.T. j. ❑Carba- <br /> mates C.❑ <br /> 13. CHAIN OF CUSTODY <br /> 248ay –!4�'YI�y4 f htf'��1`�YYI S.._ — /k� <br /> Si nature Name/Title 'Inclusive Dates <br /> b. ��% fLC /y _ <br /> atu Name/ 'tle ;t -Inclusive Dates <br /> C. " r '. �'�-...o S� AV& -. <br /> Signature. . _ Name/Title Inclusive Dales _ <br /> Signature Name/Title Inclusive Dz.es <br /> - <br /> 14.'SPECIAL REMARKS-'---"- <br /> W. <br /> 15. RECEIVED BYE -:,Sc � J��'., >', ;, .a.Title �LL� c b. Date - - <br /> 16. SAMPLE`ALLOCATION a. >HML-Berkeley b. ❑ HML-SC c. ❑ AIHL d. C3 Contract' b. Date <br /> 17. ANALYSIS REQUESTED L <br /> A <br /> " - - B <br /> OHS 8002(Rev 7/87) Original-Lab • Duplicate-File Triplicate-Inspector NLY(HML) <br />