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Submission Form - Anresco Laboratories

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Specializing in Quality, Safety and Nutritional Content Analyses

Address packages(s) to:

ANRESCO LABORATORIES

1375 Van Dyke Avenue, San Francisco, CA 94124 USA

Phone: (415) 822-1100 / Fax: (415) 822-6615

ATTN: Lab Sample for Analysis

Please complete this form, excluding shaded areas, and enclose it with your sample. Enter full contact info below or attach your

SUBMISSION FORM:

business card. Keep a copy for your records.

CONTACT INFORMATION

ANALYSIS INFORMATION

Company Name:

Anresco File #:

Contact Name:

Time Received:

via:

ambient

refrigerated

frozen

Email:

Project/P.O. #:

Condition:

yes

no

Tel:

Fax:

Seal Intact?

Street Address:

Storage Location:

City, State, Zip:

Received by:

Date:

SAMPLE DESCRIPTION AND ANALYSIS REQUIRED

On the left side below, please provide a description of your sample(s). On the corresponding line to the right, list analysis(es) to be performed. Note any special instructions at the bottom of this form.

Sample Description

Lot/Code

Date/Time

Analysis

Anresco

Include brand/label, size/weight, storage condition, packaging

Number:

Collected:

File #

if applicable.

(if applicable)

SERVICE TYPE (check the applicable box)

Routine turnaround (ranges from 10-15 days) is the default.

Rush Service

If sample is received before 10:30 am, Day 1 of the turnaround

All rush services must be preapproved. Rates may not apply to all analysis. Please contact your representative.

will start the same day. Otherwise, Day 1 will begin the following

5 Day TAT (50% surcharge)

3 Day TAT (100% surcharge)

business day.

2 Day TAT (200% surcharge)

Next Day (300% surcharge)

Special Instructions:

Check here if you want your sample to be returned to you (if any is remaining and at your expense) or if you wish to pick up (no charge). Otherwise, please be advised that all samples will be disposed of at a

minimum of 30 days after reporting results; perishable samples will be retained for a minimum of 5 working days.

Check here if sample is hazardous material. Hazardous material samples will be accepted for analysis under the condition that if any is remaining, it may be returned to customer. A return fee and/or

disposal charge will be added to the analysis fee (minimum charge $50.00).

OTHER:

Revision: 8

Date Approved: 05/13/16

Approved by: NgaLy Frank

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