Analytical Request Form
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ANALYTICAL REQUEST FORM
ISO/IEC
17025
9240 Santa Fe Springs Road, Sant a Fe Springs, CA 90670
562.948.2225
Fax 562.948.5850
Cert: 3248.01
w w w . e x o v a c h e m i s t . c o m
Send Report To
Send Invoice To
Contact: _____________________________________________
AP Contact: __________________________________________
Company: ____________________________________________
Address: _____________________________________________
Address: _____________________________________________
_________________________________________________________
______________________________________________________
________________________________________________________
__________________________________________________________
Project: ______________________________________________
Email: ______________________________________________
Purchase Order: _______________________________________
Phone : ______________________Fax: ____________________
Phone : ______________________Fax: ____________________
Regulatory Requirements
Storage
Reporting Options
Turnaround Time (business days):
ISO 17025 Traceability Required
Report Only
Protect from light
Date Data Due: ________________
R&D or Internal (not submitted to FDA)
+ Spectra/Chromatograms
Room T emp
Normal 10 days
(routine analyses)
Regulatory Submission to FDA*
2 to 8º C
+ QA Data Pkg (extra fee)
Rush 5 days
}
Rush fees
Product/Raw Material Regulated by FDA*
-10 to -25º C
Mail
Rush 3 days
will apply
Send by
Other ____________________________
-70 to -90º C
Email
Rush 1 day
Radioactive Material ______ mCi
DEA Controlled Substance/Chem: Sched - ______
(Limit = 10 mCi - samples/preps will be returned)
Comments and Precautions (MSDS Must be included with all samples)
Sample Identification
Analysis(es) and Specifications*
Matrix/Product
for Report
________________________________________________________________________________________________________________________
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
* Specifications are required for all FDA cGMP work.
________________________________________________________________________________________________________________________
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
________________________________________________________________________________________________________________________
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
________________________________________________________________________________________________________________________
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
________________________________________________________________________________________________________________________
To ensure compliance with cGMP requirements, non-compendial test methods must be transferred and/or validated. Method transfer and/or validation services are available on request
and are the responsibility of the client. Where method transfer and/or validation have not occurred reports will indicate “meth
od not validated for this matrix at this facility .”
________________________________________________________________________________________________________________________________________________________________________________
Relinquished by:
Company:
Date
Time
Received by:
Company:
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Relinquished by:
Company:
Date
Time
Received by:
Company:
NOTES: Samples will be disposed of 30 days after invoicing, except for regulated substances and
Job No.: ___________________
radioactive samples which will be returned at the client’s expense. All documents and raw data will be
disposed of af ter 7 years. All services provided will adhere to Exova Inc Terms & Conditions.
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Parent category: Business