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State of California-Health and Welfare Agenc, Department of Health Services <br /> 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 /> I_ 5. Priority <br /> 142 - Mg P a. Authorized by <br /> 6. Date Sampled 7. Time Sampled , � Hours 8. Codes (fill in all applicable codes) <br /> 9. Activity [] Enf ASury ❑ Site Mit ❑ Permittinga. STC , „1 <br /> ❑ Ait Tech El <br /> b. Region <br /> 10.SAMPLING LOCATION (� (�' (� �J c. TPC <br /> a. EPA ID No. <br /> r <br /> d. INDEX <br /> b. Site 11n1� P_Sc�r't f�Y) e. PCA - <br /> 11II oU i <br /> c. Address i(1 C?r l.l Y1 I n)-, ��/l.V 4 o cx_ f. SITE <br /> Number Street City Zip g. County <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 /> B. 13�h� �� 44 � t <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 I. ❑ PCB (Screeng) <br /> a. ❑ pH g. ❑ VOA I. ❑Chlorinated <br /> Pesticides <br /> b.❑Metal h. ❑ PAH m. ❑Organo-P <br /> Scan Pesticides <br /> C.❑Metals <br /> (Spec) i. ❑ Phenols n. ❑ <br /> Carba- <br /> d.❑ W.E.T. ❑mates o ❑ <br /> 13. CHAIN OF CUSTODY <br /> r Signature Name/Title lrclusive Dates <br /> b. <br /> Signature Name/Title inclusive Dates <br /> C. <br /> Signature Name/Title Inclusive Dates <br /> d. <br /> Signature Name/Title 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. ❑ Contract b. Date <br /> 17. ANALYSIS REQUESTED L <br /> A <br /> B <br /> DHS 8002(Rev 7/87) Original-Lab 9 Duplicate-File • Triplicate-Inspector NLY(HML) <br />