PT.NIKEL NUSANTARA MANDIR} F1.n2N4.001.x1.29 D FORMULIR PERMINTAAN PENGUJIAN LABORATORIUM 20 Form of Sample Laboratory Test Order Tebect Nomor Order/ Job Order No Report No 2392 Data Pelanggan/ Customer Data ‘Nama Pelanggan/ Customer Nome Pre ‘Alama Pelanggan/ Customer Adoress Desa Ulla Telepon/ Phone ‘Surat Elektronik/Emoi! Jumtah Sample/ Sample Amount 7 Samples Ore Nickel ‘Tanggal/ Waktu Penerimoan Sample 18 Desember 2021 Affe to be order a sample test or analysis of Kode ond Sample Tetode Uji [Barat Sampet_| Biaya per Parameter [Total Bava Sample [Sample Condition | Test Method Ne | sample |83594/| emasan/aag | Press | Press | Sample Weight | CostotSample | Total cost Code | Kering "© | powder| Pellete a | 7 [Keine] Crt +L 2 Rp 150000000 | Re _1.050.000,00 ‘ang Muko/ Down Payment| Rp Diskon/ Discount “anil Bioya Somple/ Total Cost of Sample | Rp 3.050,000,00 Catatan/ Note: List Sample Terampie Penerima Pengirim Sample Received by, ‘Sender by riya way ‘ss of ab Analyst Laboratory +) Formulir ini sebagal bukti pemesanan pengujlan dan akan mematuhi peraturan yang berlaku This form authentically proves the order ond oplicant approves tobe obey the prevailing rules Bank Account PT Nikol Nusantara Mandir MANDIR