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Hazardous Materials a.ahor_atory•Section <br /> SAVE SAI•ik -1:. (S) REQUEST FORM <br /> . tam <br /> Save samples until <br /> (cage) <br /> Reason for paving Sai::p:.es: _; ^ <br /> (Signai:u::a o% cullectorl. (Date..)~� <br /> _ If ht•T S does not receive a completed "Save Sample(s) ReaL es-", the <br /> samples will be disposed ( 0 days fzo:n the date of the final a7aJtical <br /> - <br /> Return completed form to: California Department of Health Services <br /> ..Hazardous Materials Laboratory Section (IM,MS) <br /> 2151 Berkeley Way <br /> Rnom 235 <br /> Berheiey, CA 94704 <br /> 8A!'21 <br /> 0ne <br />