Da Form 7539 - Request For Veterinary Laboratory Testiong & Food Sample Record Page 2
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2(Complete as much information as is available):
13. SAMPLE INFORMATION
LAB REPORT #
FOR LABORATORY USE ONLY
SAMPLE NUMBER 1
SUBMITTER SAMPLE NUMBER
SAMPLE DESCRIPTION
BRAND NAME
UNIVERSAL PRODUCT CODE (UPC)
PRODUCT CODE
SAMPLE WEIGHT/VOLUME
QUANTITY SUBMITTED
UNIT OF ISSUE
TOTAL COST
DISPOSITION
FOR LABORATORY USE ONLY
SAMPLE NUMBER 2
SUBMITTER SAMPLE NUMBER
SAMPLE DESCRIPTION
BRAND NAME
UNIVERSAL PRODUCT CODE (UPC)
PRODUCT CODE
SAMPLE WEIGHT/VOLUME
QUANTITY SUBMITTED
UNIT OF ISSUE
TOTAL COST
DISPOSITION
FOR LABORATORY USE ONLY
SAMPLE NUMBER 3
SUBMITTER SAMPLE NUMBER
SAMPLE DESCRIPTION
BRAND NAME
UNIVERSAL PRODUCT CODE (UPC)
PRODUCT CODE
SAMPLE WEIGHT/VOLUME
QUANTITY SUBMITTED
UNIT OF ISSUE
TOTAL COST
DISPOSITION
FOR LABORATORY USE ONLY
SAMPLE NUMBER 4
SUBMITTER SAMPLE NUMBER
SAMPLE DESCRIPTION
BRAND NAME
UNIVERSAL PRODUCT CODE (UPC)
PRODUCT CODE
SAMPLE WEIGHT/VOLUME
QUANTITY SUBMITTED
UNIT OF ISSUE
TOTAL COST
DISPOSITION
FOR LABORATORY USE ONLY
SAMPLE NUMBER 5
SUBMITTER SAMPLE NUMBER
SAMPLE DESCRIPTION
BRAND NAME
UNIVERSAL PRODUCT CODE (UPC)
PRODUCT CODE
SAMPLE WEIGHT/VOLUME
QUANTITY SUBMITTED
UNIT OF ISSUE
TOTAL COST
DISPOSITION
FOR LABORATORY USE ONLY
SAMPLE NUMBER 6
SUBMITTER SAMPLE NUMBER
SAMPLE DESCRIPTION
BRAND NAME
UNIVERSAL PRODUCT CODE (UPC)
PRODUCT CODE
SAMPLE WEIGHT/VOLUME
QUANTITY SUBMITTED
UNIT OF ISSUE
TOTAL COST
DISPOSITION
FOR ADDITIONAL SAMPLES, USE ADDITIONAL COPIES OF PAGE 2.
APD 9V1.000
DA FORM 7539, FEB 2005
PAGE 2 OF 2
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