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State of California-California Environmente tet...-.l ency Department of Toxic Substances Control <br /> Hazardous Materials Laboratory <br /> HAZARDOUS MATERIALS 1. Authorization Number HML No. 1(001b-1 2. Page I <br /> SAMPLE ANALYSIS REQUEST I A.1n lD To (�0�1tpE / of <br /> 3. Requester: NawLofl(,�ier' 4. Phone( ?(-II 5. Priority Level: 1 2 3 <br /> Address(To Recei Results): ( 15I t(CI i t�1 ` < (t) a. Authorized by <br /> 6. Date Sampled I I 7. Time S1ampled /� a Hours 8. Codes(fill in allapplicablecodes) <br /> a. STC <br /> 9. Activity: SEB E] SMB ❑ FPB ❑ FMB ❑ HQ ❑ OTHER b. Region <br /> 10. SAMPLING LOCATION c. INDEX <br /> ` a. EPA ID No. d. PCA <br /> b. Site ' ( � 1 E C C e. MPC <br /> f.SITE () Z <br /> c. Address L L - h I n k C lU g. County <br /> Number Weal CM 1zip <br /> 11. SAMPLES �')--i( UL <br /> Sample Container <br /> a. ID b. Collector's No_ c. Lab No. d. Type e. Type f. Size g. Field Information - <br /> A I L , sz Ee n II <br /> C F <br /> I <br /> D E <br /> E L <br /> F D <br /> G <br /> H <br /> 12. ANALYSIS REQUESTED f. ❑ VOA-8020 I. ❑ Flash <br /> _I Point <br /> a. pH L g. ❑ VOA-H/S m.❑ C1-Pes- <br /> p�, ticides <br /> Metal h. ❑ VOA-8240 n. ❑ OP-Pes- <br /> Scan (,Y ticides <br /> C. [ f Metals i. ❑ VOA-8260 o. ❑ <br /> (Spec) <br /> d. W.E.T. R 1 1�rtFlry 1. ❑ SVO-8270 P. ❑ <br /> Diesel/ <br /> e. ❑ VOA-8010 k. ❑ Gasoline q. ❑ <br /> 13. SPECIAL REMARKS: <br /> 14.SUPPLEMENTAL © ©' <br /> Initials. <br /> REQUESTS <br /> © ❑ Date <br /> 15. CHAIN OF CUSTODY <br /> a. /._. . , - :; -� . / c�r7 r• � I rte ' c� �/' �.F.�(S. // d (� IF- it �e2 SG <br /> gnatu,a/ r �yWmsj/�UI� Incluse a Dates <br /> v 1 ( l l � r f <br /> b. NaaaRlp. Inclusive Dates <br /> / azure <br /> D.`�- - t`_.f -Y� c f�I r I f'�C(1 tl- 4� SSi . I 2v <br /> $Ienemre Neme/Tnle Inclusive Dates <br /> d' Slgnetura • NemeRitla Inclusive Data. <br /> ` <br /> 16. LAB REMARKS: ( � .1'! P 1 �' r i I LA <br /> �b ( Il B <br /> DTSC 1116(REV.1/94) Original-Lab • Duplicate-File a Triplicate-Inspector NLY(HMW <br /> 1Formerly DHS 80021 <br />