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St.te of Callfoinla--Health and Welfare Agency Department of Health Services <br /> HAZARUoUS MATERIALS SAMPLE ANALYSIS REDL—iT <br /> PRIORITY HML NosCIO, To <br /> To <br /> (Explain) `'` ^ L <br /> .RT I: FIELD SECTION <br /> Collector �' ' Date Sampled n I1 I Time ' Hours <br /> I t <br /> Activity: � Enforcement ❑ ASP EDH.W. Property 11 Super ❑ Other ❑ RCRA OPT Code <br /> Region: 7 PMS—SAC NCS—SAC ❑ NCS—FRESNO ❑ SCS—LA ❑ NCCS—BERK <br /> LOCATION OF SAMPLING: <br /> Nam -� Tel. No <br /> Address I A- e4l -�eec;n y' <br /> Number Street city Zip <br /> HML No. Collector's Type Of <br /> (Lab Only) Sample No. Sample' FIELD INFORMATION <br /> C 1_0 �1_a `Z0 X11_ CrAR��rJ <br /> C-11 Z Z- mor L <br /> —r <br /> q1-1 PI^"- X75 ��> 1 �NT-U-, <br /> Analysis Requested: <br /> Chain ofiC,(�fstody: i <br /> //II ��� <br /> SIg ure Title Inclusive Dates <br /> yl1, t 2 7 _ <br /> 2g lhh <br /> ure Title inclusive Date <br /> Signature Title Inclusive Dates <br /> 4. <br /> Signature Title Inclusive Dates <br /> 5 Signature Title Inclusive Dates <br /> Special Remarks <br /> (e.g.,duplicate sample given to company,etc.) <br /> PART II: LABORATORY SECTION <br /> Received By `^' Title Date <br /> Sample Allocation: ❑ HML ❑ SCBL o❑ LBL ❑ Other Date <br /> Analysis Required <br /> "II. ih.-r salllple is sludge, soil,etc. Orig.—Lab. Dup.—File Trip.—Inspector <br />