ILC MICRO-CHEM INC.

QSF 035.4
Effective:May 2009
Replaces: July 2008
Approved by: Ash Mathur
SAMPLE SUBMISSION FORM
for Chemical and Microbiology Analysis
ILC MICRO-CHEM INC.
6535 Millcreek Dr. Unit 62, Mississauga, ON L5N 2M2
Ph: 905-858-8630 Fx: 905-858-0771
ILC REPORT NUMBER
CHAIN OF CUSTODY RECORD
Report Information
Company:
Contact:
Address:
Invoice Information
Company:
Contact:
Address:
Phone:
Email:
Phone:
Email:
Fax:
Additional Reporting Information
(Same as Report Information)
Fax:
Date Rec'd by ILC
Temperature on
Receipt
PO#
Quote #
Indicate analysis and method required
Date Required
Rush
Please contact the laboratory to confirm rush
dates and times before submitting samples.
Authorized Customer Signature
Upon filling out this section, client accepts that surcharges
will be attached to this analysis
ILC Rush Acceptance Signature
Required on :
All Analysis
or
As Indicated
Sample Identification
Date Sampled
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All samples must be clearly identified and all applicable areas of the submission sheet completed. Improper or incomplete submission sheets may result in delayed sample
processing. If method is not specified, lLC will use official methods based on sample matrix. If sample is sent ground, please provide sufficient sample description. Please refer to
www.industriallabs.ca for information on sampling and details on submitting samples for testing.
Relinquished by: (Signature/Print)
Received by: (Signature/Print)
Date/Time
Purpose of Change/Remarks
QSF 035.4
Effective: May 2009
Replaces: July 2008
Approved by: Ash Mathur
SAMPLE SUBMISSION FORM
for Nutritional Analysis
ILC MICRO-CHEM INC.
6535 Millcreek Dr. Unit 62, Mississauga, ON L5N 2M2
Ph: 905-858-8630 Fx: 905-858-0771
ILC REPORT NUMBER
CHAIN OF CUSTODY RECORD
Invoice Information
Company:
Contact:
Address:
Phone:
Email:
Fax:
Additional Reporting Information
ILC Rush Acceptance Signature
Required on :
All Analysis
As Indicated
or
Sample Identification
Date Sampled
Nutritional Claims
Upon filling out this section, client accepts that surcharges
will be attached to this analysis
Metric Weight / Volume of
serving: (specify g or mL)
Authorized Customer Signature
Product Category: ( refer to
Schedule M / Table 6.3*)
Please contact the laboratory to confirm rush
dates and times before submitting samples.
US NFP Required (PDF
format)
Rush
CDN / US Nutritional by
Analysis
CDN NFP Required (PDF
format)
Indicate analysis and method required
Date Required
Servings per container (US
requirement)
Fax:
Temperature
on Receipt
PO#
Quote #
Density (g/ mL). Required
for serving declared by
volume
Phone:
Email:
Date Rec'd by ILC
(Same as Report Information)
Serving Size Description
(use household measure
nearest to reference amount
in Schedule M and / or
Table 6.3* i.e. per cookie,
per slice, per 1/2 cup, etc.)
Report Information
Company:
Contact:
Address:
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2
3
4
5
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8
9
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11
12
All samples must be clearly identified and all applicable areas of the submission sheet completed. Improper or incomplete submission sheets may result in delayed sample processing.Please refer to
www.industriallabs.ca for information on sampling and deta
Relinquished by: (Signature/Print)
**NFP=Nutrition Facts Panel
Received by: (Signature/Print)
Date/Time
Note: All CDN NFP will be supplied in 3.1B format if Available Display Surface has not been provided
Purpose of Change/Remarks
QSF 035.4
Effective: May 2009
Replaces: July 2008
Approved by: Ash Mathur
SAMPLE SUBMISSION FORM
for Waste Water Analysis
ILC MICRO-CHEM INC.
6535 Millcreek Dr. Unit 62, Mississauga, ON L5N 2M2
Ph: 905-858-8630 Fx: 905-858-0771
ILC REPORT NUMBER
CHAIN OF CUSTODY RECORD
Report Information
Company:
Contact:
Address:
Phone:
Email:
Invoice Information
Company:
Contact:
Address:
Phone:
Email:
Fax:
(Same as Report Information)
Temperature on
Receipt
PO#
Quote #
Fax:
Additional Reporting Information
Sampling Location
Sampled by:
Special Instructions /comments:
Sample Identification
Date Sampled
Sampling Method
Preservatives Added (Y/N)
Indicate analysis and method required
Project Name:
# of containers submitted
Projec t ID:
Date Rec'd by ILC
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All samples must be clearly identified and all applicable areas of the submission sheet completed. Please refer to www.industriallabs.ca for information on sampling requirements
according to MISA guidelines and details on submitting samples for testing i
Relinquished by: (Signature/Print)
Received by: (Signature/Print)
Date/Time
Purpose of Change/Remarks