Appendix II – 1

Republic of the Philippines

OFFICE OF THE DISTRICT ENGINEER
Masbate II D.E.O
Dimasalang, Masbate

SAMPLE CARD (For Government Project)

Project :
______________________________________________________________
(Name) (City/Province)

Kind of material :______________________________________________________________

Sample identification :______________________________________________________________
Quantity represented :______________________________________________________________
Sampled at :______________________________________________________________
(Give accurate location possible)
Original Source :______________________________________________________________
Owner / Supplier :______________________________________________________________
Sampled by :________________________ _____________________ ________________
(Name & Designation) (Office) (Date)/ Signature
:________________________ _____________________ ________________
(Name & Designation) (Office) (Date)/Signature

Proposed use :______________________________________________________________

Test desired :______________________________________________________________
Governing Specification :_______________________________________________________________
Shipped by :________________________ _____________________ _______________
(Name & Designation) (Office) (Date)/Signature

:_______________________ _____________________ ________________

(Name & Designation) (Office) (Date)/Signature

Send Test Results to :______________________________________________________________

______________________________________________________________
(Mailing Address)
REMARKS :______________________________________________________________
Bill charged to :______________________________________________________________
Submitted by :___________________________________ __________________________
(Name) (Signature)

____________________________ __________________________________
(Office) (Mailing Address)

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Received by: ________________________________ Lab. No. :_______________________