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Vices <br /> State Of�'iBrfCIRi19-Health and W _.�•••.••-.-_._ r. ..__. -. . :OE> S01' <br /> HemodmamnswiekkulbMtory <br /> HAZARDOUS MATERIALS 1.Authori ' - H Z Pago <br /> SAMPLE ANALYSIS REQUEST <br /> 3.Requestor: .41o#._ ?.-fd 4.Phone,jiff 4t r - 2L 1_ & ALWi. ;, <br /> Address(To Receive Results): /(r/1% (✓ f� a' _ a <br /> 6. Date Sampled P 7.11meSampled Hours &Codes(tilrimail.applicable codes) <br /> 9.Activity: 0-43EB CI SMB ❑FPB ❑ATD 0 PASD 0 Other a.STC <br /> c7 (? <br /> b. Region- <br /> 10:SAMPLING LOCATION c.TPC <br /> a. EPA ID No. d. INDEX <br /> b. Site G�� C�c7 e. PCA <br /> f. SITE <br /> c. Address S ` , C�C 64 7f g. County <br /> Number sumo city zip <br /> 11.SAMPLES <br /> Sample Container <br /> a. ID b. Collector's No. c. Lab No. d.Type e.Type yyf.Size g. Field information <br /> C F <br /> D I <br /> E L <br /> F D <br /> G <br /> H <br /> 12.ANALYSIS REQUESTED f . ❑ PCB k.❑ Ext. Org <br /> � E (Screening) <br /> a.� pH g.❑ VOA-HIS i.❑ Flash <br /> �7 Point <br /> b Metal ,13 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 /> 13SUPPLEMENTAL ❑ ❑ Initials <br /> REQUESTS <br /> ❑ ❑ Date <br /> 14.CHAJIgI OF COSTO Y <br /> lodunm�. <br /> b. <br /> Si�uvm NsAWMD lavumm Dues <br /> C. / / - / / <br /> S mm N.ms/reb Indurv.Dues <br /> d. / / - / / <br /> S N.nwfl-m. brclurv.Dues <br /> 15.SPECIAL REMARKS: <br /> 16.ASSIGNED TO: Date <br /> 17.LAB REMARKS: L <br /> A <br /> B <br /> DHS 8002(Rev 10/90) Original-lab Duplicate-Fiie TnDlecate-Inspector NLY(HML) <br />