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• <br /> Stm.ot is-H and'Welfare Agency <br /> `RDOS A IA ,. r <br /> SAMPLE: ANALYSIS, E <br /> 3:R r~,A/A- ' 7-Ad 4.Phol <br /> _ � <br /> Address(To Receive Results): /4,/J'/ 4./ 60 .A;: . P1, <br /> 6.Data Sampled 7.11ime,Sampled: Hours rCoIEie>�allc <br /> 9.Activity:. W?SEB 0 SMB- 0 FPB 0 ATD- O PASD 00ther-.. <br /> Ix Region:- <br /> 10.SAMPLING LOCATION'.- c TPC 4' <br /> �^� ( a..EPA ID No. d. INDEX <br /> b.Site /��� r-^� C17 e.PCA 3 ` v <br /> f.SITE <br /> C.Address S ` ""` C " 7 L&& g.County <br /> —_x weftCky zip <br /> 11.SAMPLES <br /> Sample Container <br /> a. ID b.Collector's No. c.Lab No. d.Type e.Type yf�Siizee g.Field Information <br /> sCMDPI& g3tm- ate-✓ <br /> 7- <br /> —��— <br /> C F <br /> D E <br /> E L <br /> F D <br /> G <br /> H <br /> 12.ANALYSIS REQUESTED f. ❑PCB k.❑ Ext. Org <br /> a.0 pH g.❑ VOA-H/S i.❑ Flash <br /> Point <br /> b Metal �� h.❑ VOA-8240 m• ❑ <br /> Scan <br /> C.❑ Metals i.❑ VOA-8260 n. ❑ <br /> (Spec) <br /> d.❑ W.E.T. j. ❑ SVO-8270 0.❑ <br /> Initials13-'SUPPLEMENTAE ❑ ❑ <br /> REQUESTS <br /> ❑<: ❑ Date:. <br /> 14.CHAJP OF CUSTODY <br /> �Ja. � �v- <br /> N <br /> n./m <br /> wan" p g `b. QvnAc , J <br /> s m n" 4r b2d=r4a Dam <br /> C. / / - / / <br /> s;m.nue <br /> d. <br /> S4"=* xawon-,a. fDduim Dam <br /> 15.SPECIAL REMARKS: <br /> 16.ASSIGNED TO: Date `� ! <br /> 17.LAB REMARKS: L <br /> A <br /> B <br /> DHS 8002(Rev 10190) Original-Lab • Duplicate-File Triplicate-Inspector NLY(HML) <br />