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State of California—Health and Welfare Agency Department of Health Services <br /> HA cJOUS MATERIALS SAMPLE ANALYSIS h_ FST <br /> PRIORITY© _, HML No. <br /> (Explain) To <br /> PART I: FIELDSECTTIION f <br /> Collector 4 ' /�! G✓f�uG14 /7 ,4PP I L lir — <br /> Date�ampled.. Time Hours <br /> Activity: &Enforcement ❑ ASP ❑ H.W. Property Q Super ❑ Other 619 RGA <br /> LOCATIONAF SAMPLING: <br /> Name Q749 b DA-) �L�-fL�4,2cff Tel. No. <br /> Address /U8 5 SDu7-1/ t11L/1D.J '/�,g y,, G`V 0/ T 3 3 G <br /> Number Street City Zip <br /> HML No. Collector's Type Of <br /> (Lab Only) Sample No. Sample* FIELD INFORMATION <br /> 4S/d - 070 Ll�uil� �lr , 9o�V�tLl�ry G�ean, .-ea <br /> 75'0, <br /> 172- 2-14p , 6:pez ear �I 1�r�uen� Xy /2 nes <br /> a na A f <br /> 074 Zlo"l <br /> Analysis Requested: 4j-1P -670 t �rGDC,e?�Z� �YriGLh-i�( �G� �I br6fCvYrt� s <br /> -l/.j'/a - G7/ tel,-r��1 �.T/vy7,�- ; G�e-r,,,�>-,� scrsp•��-�� yv��e----��r <br /> Chai o � <br /> 7CC <br /> /1 _ CSign re Ti Q Inclusive Dates n o <br /> 2. 6 y 18 /Z�/'r L 87 _ '16) /�//tYL/ l <br /> Signature Title Q Inclusive Dates <br /> 3. P2// 1J '�// <br /> Signature Title Inclusive Dates <br /> 4. <br /> Signature Title Inclusive Dates <br /> Special Remarks <br /> (e.g.,duplicate sample given to company,etc.) <br /> PART II: LABORATORY SECTION <br /> Received By 16A& AC Titlez() <br /> _:�&" - - Date 494- <br /> Sample Allocation: ❑ HML VO SCBL ❑ LBL W Other Date <br /> Analysis Required <br /> *Indicate whether sample is sludge, soil,etc. <br /> Orig.—Lab. Dup.—File Trip.—Inspector <br /> DHS 8002 (9/82) <br />