42268

LABORATORY TEST REQUEST

CRP CENTRO PARA LA PREVENCION RIESGOS
CRA 7 No. 156 - 68
OFICINA 1506 - EDIFICIO NORTH POINT
BOGOTA - COLOMBIA, PI
Phone: 571-474-7575
Fax: 011-571-354-4123

CODIGO: LS-R-07

EMISION:20/08/2010

DATE SHIPPED

# OF SAMPLES

SAMPLE TYPE/MEDIA

PROJECT NAME OR NUMBER

21/09/2015

PVC

Pacific Startus Energy-Copa

PURCHASE ORDER No.

CONTACT

TELEPHONE NUMBER

0325

ALVARO ARAQUE

4747575

SPECIAL INSTRUCTIONS AND/OR UNUSUAL

CONDITIONS:

TURN AROUND TIME S

SAME DAY

2 DAY

1 DAY
CALL FOR AVALIABILITY

FOR LABORATOTY USE

ONLY

FAX RESULTS FAX NUMBER:

( )___________________

STANDARD

EMAIL RESULTS - EMAIL:

EXTRA CHARGE

( )___________________

SAMPLE # OR SAMPLE
AREA

SAMPLE DATE

SAMPLE
VOLUME/LITERS

111114-73

26/08/2015

1180,6 lts

052815-37

26/08/2015

1193,9 lts

ANALYSIS REQUESTED-PLEASE USE

SEPARATE LABORATORY TEST REQUEST
FOR EACH SAMPLE TYPE
SILICA-CRYSTALLINE PROFILE/NIOSH
7500
SILICA-CRYSTALLINE PROFILE/NIOSH
7500

CHAIN OF CUSTODY RECORD

_________________________________________

SAMPLES HAVE BEEN SEALED FOR TRANSPORT AND DELIVERED TO LABORATORY VIA:

SIGN HERE TO INITIATE CHAIN OF CUSTODY

___________________
CARRIER
DATE / TIME

____________________

___________________________________

IF ANALYTICS COURIER SIGN HERE

CONDITION OF SAMPLE

DATE

SIGNATURE RECEIVED BY:

SIGNATURE (SAMPLE RECEIVING)

SAMPLE RELEASED BY:

SIGNATURE (SAMPLE RECEIVING)

SIGNATURE (SAMPLE RECEIVING)

SIGNATURE (SAMPLE RECEIVING)

SIGNATURE (LAB)

SIGNATURE (LAB)

SIGNATURE (LAB)

SIGNATURE (LAB)