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State of California-California Environmental ; Agency — Department of Toxic Substances Control <br /> Hazardous Materials Laboratory <br /> HAZARDOUS MATERIALS 1. Authorization Number HML No. -1:S 1 15( 2. Page <br /> SAMPLE ANALYSIS REQUEST 3 11 11 19 To uCp0 3 of f <br /> v <br /> 3. Requester: � Qn� U✓` e r 4. Phone( 0 9 / - 3�f�5 5. Priority Level: 1 2 3 <br /> Address(To Receive esults): J r (DI 1C1T t —�4 1 a. Authorized by ZU du LR <br /> 6. Date Sampled I aLl 9 1 7. Time Sampled /C .C&Hours S. Codes(fill in all applicable codes) <br /> 9. Activity: SEB ❑ SMB ❑ FPB ❑ FMB ❑ HQ ❑ OTHER a. STC (� <br /> C //�� b. Region <br /> 10. SAMPLING LOCATION Q S 0 .3 c. INDEX <br /> a. EPA ID No. d. PCA <br /> b. Site ` )� e. MPC <br /> I,SITE G Q (_'I I <br /> c. Address u•� I ))F ( kv) Ig. County <br /> Number Street CM (?SA v81 <br /> 11. SAMPLES ("7UX <br /> Sample Container <br /> a. ID b. Collector's No. c. Lab No. d. Type e. Type f. Size g. Field Information <br /> A G�JG Yj 6 <br /> B c.I LnCrl �t I J� <br /> C N VL 6' ) j (11 Li u, a F <br /> I <br /> D H tr0—Ici-7 E <br /> E N ILL L (oI L <br /> F C4 (t, <br /> 1 o c1 D <br /> H <br /> 12. ANALYSIS REQUESTED f. ❑ VOA-8020 I. ❑ Flash <br /> / Point <br /> a. X_pH _C —`-' v g. ❑ VOA-H/S m.❑ C1-Pes- <br /> �� _p J tlotdes <br /> b. Metal h. ❑ VOA-8240 n. ❑ OP-Pes- <br /> Scantb $ F / ticides <br /> C. �] Metals (_ V i. ❑ VOA-8260 0. <br /> (Spec) 1111�a1S <br /> d. Y� W.E.T. A f (1P(' t (y j. ❑ SVO-8270 P. ❑ <br /> r Diesel/ <br /> e. ❑ VOA-8010 It. ❑ Gasoline q. ❑ <br /> 13. SPECIAL REMARKS: <br /> 14. SUPPLEMENTAL ❑ ❑', initials <br /> REQUESTS © ❑ <br /> Date <br /> 15. CH I OFCUST DY �L / <br /> a. Aa. ,c�TVI< < C r 5 -1 <br /> 5urs Nams/TM. Inclusive Dates <br /> b. I < < n <br /> pet is _�. Nems/TRIo Inclusive Dates <br /> C-1 > `� errt1-0. GII(� L.L+1� s-1 � ' r) <br /> C. <br /> _ Sipneture Neme/Titla Inclusive Dates <br /> d. <br /> Slynature • NamaRitle Inclusive Dates <br /> 16. LAB REMARKS: L <br /> A <br /> B <br /> DTSC 1116(REV 1/94) Original-Lab • Duplicate-File • Triplicate-Inspector NLY JHML) <br /> (Formerly DHS 8002) <br />