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-State of Calfornia-California Environment )tt.,_n Agency Department of Toxic Substances Control <br /> Hazardous Materials Laboratory <br /> HAZARDOUS MATERIALS 1. Authorization Number HML No. 1777 2. Page <br /> SAMPLE ANALYSIS REQUEST n� �j To uA/-C /C 0 of <br /> 3. Requester: ay i(\' (,Lys 0 Q r 4. Phone( E )9 q - 3( qS_ 5. Priority Level:a. Authorized b 2 <br /> 1 2 3 <br /> Address(To Receive sults): 1,I �' (4( j_ � !1 t77 y t <br /> 6. Date Sampled 7. Time Sampled /O Hours B. Codes(fill in all applicable codes) <br /> 9. Activity: SEB El ❑ FPB E] FMB [3HQ ❑ OTHER a. STC (� O <br /> //,, b. Region Q ' <br /> 10. SAMPLING LOCATION V c. INDEX <br /> a. EPA ID No. d. PCA <br /> b. Site rl "t ' o e. MPC <br /> r f, SITE 0 <br /> c. Address r h ) �- g. County <br /> Number street Diry zip <br /> 11. SAMPLES qs t og <br /> Sample Container <br /> a. ID b. Collector's No. c. Lab No. d. Type eI. Size g. Field Information <br /> A I I�L1•• <br /> B <br /> C KL j(o7 l4. ? F <br /> D <br /> E ` G ` _ E <br /> L <br /> F ) D <br /> H L cI i ITT T5J- <br /> G C�O-l9 h t. <br /> 12. ANALYSIS REQUESTED\ I. ❑ VOA-8020 I. ❑ Flash <br /> Point <br /> a. pH ✓ g. ❑ VOA-H/S m.❑ C1-Pes- <br /> ticides <br /> b. Metalh. ❑ VOA-8240 n. ❑ OP-Pes- <br /> Scan ticides <br /> C. Metals 'f b �$CJ! ) i. ❑ VOA-8260 0. <br /> (Spec) \ K1e'tCt <br /> d. Pf W.E.T. 1Q�j. ❑ SVO-8270 P. ❑ <br /> Diesel/ <br /> e. ❑ VOA-8010 k. ❑ Gasoline q. ❑ <br /> 13. SPECIAL REMARKS: <br /> 14.SUPPLEMENTAL ❑ ❑ Initials <br /> REQUESTS <br /> © Date <br /> 15. CHAT J.OF CUSTODY <br /> a. <br /> Si net Na Rle <br /> Inclusive Dates <br /> b. i <br /> "Tick-111j, <br /> g t ° Name/Tnls Ina uvve etas <br /> C. � c� cv._r, C-,ti- Ter a ��.� 111 ton /ts1�,A�s-� v� 7'l <br /> Slgnetura Name/Tltle Induuva Dates <br /> d. <br /> Signature Name/Title Inclusive Dates <br /> 16. LAB REMARKS: <br /> L <br /> A <br /> 8 <br /> DTSC 1116(REV. 1/94) Original-Lab • Duplicate-File • Triplicate-Inspector NLY(HML) <br /> (Formerly DHS 8002) <br />