Sample Submission Shipping Form
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1Sample Submission Shipping Form
General Information
Requestor Information
Date:
Requestor Name:
Cerium Contact:
Company Name:
Job Number (optional):
Address:
Number of Samples:
Email Addess:
Website:
Phone Number:
Lab Collector:
Sample Information
Please Provide MSDS
Sample #
Solid
Liquid
Gas
Hazardous/Toxic
Note: Liquid samples require secondary containment within the box with sufficient packing material.
Analysis Technique:
Volume or mass:
Sample Material:
Description:
Sample History if
Material is Unknown:
Please Provide MSDS
Sample #
Solid
Liquid
Gas
Hazardous/Toxic
Note: Liquid samples require secondary containment within the box with sufficient packing material.
Analysis Technique:
Volume or mass:
Sample Material:
Description:
Sample History if
Material is Unknown:
For shipping regulations, please refer to the United States Federal Regulations: CFR 49 Sec 173
WARNING: Failure to comply with all respects with the applicable Dangerous Goods Regulations may be in breach of applicable law,
subject to legal penalties. Improperly packaged or radioactive samples will not be accepted.
I hereby declare that the contents of this shipment are fully and accurately described above by
the proper shipping name, and are classified, packaged, marked and labeled, and are in all
respects in proper condition for transport according to applicable International and national
Governmental Regulations. I declare that all of the applicable transport requirements have
been met.
Signature
Please ship to one of the following and include as many forms needed for the amount of samples submitting
AUSTIN, TX
Salem, NH
Hazardous Material
All Other Samples
Cerium Laboratories, LLC
Cerium Laboratories, LLC
Cerium Laboratories, LLC
12 Manor Parkway, Suite 2A
5204 East Ben White Blvd.
5204 East Ben White Blvd.
Salem, NH 03079
Bldg 4 Chemical Dock
Bldg 1, M/S 662
Attn: Ihab Abdelrehim
Austin, TX 78741
Austin, TX 78741
Attn: Belinda Craven
Attn: Belinda Craven
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