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State of California-California Environmental n."a Agency 1 Department of Toxic Substances Control <br /> Hazardous Materials Laboratory <br /> HAZARDOUS MATERIALS 1. Authorization Number HML No. �v-, i K 1 2. Page <br /> SAMPLE ANALYSIS REQUEST I f} JAI j1' 3 9 To C.14,�ou Of <br /> 3. Requester: ui C im X615 e 4. Phone 1, S IH Cf - L�`f S 5. Priority Level: 1 2 3 <br /> Address(7o Receive esults):�0/SI �(() ��1 (Uq — 4L a. Authorized by <br /> 6. Date Sampled 4 19 , 7. Time Sampled /� .�V Hours 8. Codes(fill in all applicable codes) <br /> 9. Activity: SEB ❑ SMB ❑ FPB ❑ FMB ❑ HQ ❑ OTHER a. STC 3 C <br /> b. Region <br /> 10. SAMPLING LOCATION 0 0 0 3 1 c. INDEX 7 111 <br /> a. EPA ID No. d. PCA <br /> b. Site i 1 1 ` n I e. MPC <br /> I I M1 <br /> C L, f, SITE Q <br /> c. Address a 1 11 �1 1 v ' L) g- County <br /> Number Street Day <br /> 11. SAMPLES (f lVl <br /> Sample Container <br /> a. ID b. Collector's No. c. Lab No. d. Type e. Type I. Size g. Field Information <br /> Ab q L00—i 7 Y, <br /> B L 0-1 CA <br /> C L 0-110 j cklanlat <br /> D L (o01 � I 1 M 11 d E <br /> E Ll(n 01 19Z� I 11\ L <br /> F x ^ <br /> GSoo <br /> H L 00 KCao 111 <br /> 12. ANALYSIS REQUESTED I. ❑ VOA-8020 I. ❑ Flash <br /> l ` Point <br /> a. pH —E G— H V g. ❑ VOA-H/S M. <br /> c1—pes-ticides <br /> b. Metal n — h. ❑ VOA-8240 n. ❑ OP-Pes- <br /> Scan •t ticldes <br /> c. Metals Cc i. ❑ VOA-8260 0. TCL <br /> (Spec) Wta <br /> d. W.E.T. P' 1F {�1( 1. [:] V SVO-8270 p •t a <br /> Diesel/ <br /> e. ❑ VOA-8010 k. ❑ Gasoline q. ❑ <br /> 13. SPECIAL REMARKS: <br /> 14. SUPPLEMENTAL Initials <br /> REQUESTS © 0 <br /> Date <br /> 15. CHAT, OF CUSTODY <br /> a. 'efoeK CT. C��/u�y �/�SS Zy - / 77 9 <br /> 5 ne r ama/T I Inclusive Dates <br /> b. tG �( al�c\r K. amtlS ( '-sr � <br /> n ure NsmaRub - dsa <br /> D. C441-1 7 <br /> 7 <br /> Slgnetwe Name/Title Inclusive Detea <br /> d signature • Nema/Tala Induaive Dates <br /> 16. LAB REMARKS: L <br /> A <br /> B <br /> DTSC 1116(REV, 1/94) Original-Lab . Duplicate-File is Triplicate-Inspector NLY(HML) <br /> (Formerly DHS 8002) <br />