Page 136 - Chem Service 2016 Catalogue
P. 136

Custom Solutions and Mixture Form
                                           Custom Solutions and Mixture Form

      Request Form  CUSTOMER NAME  ______________________________________  COMPANY NAME _________________________________________  EPA Method Form
           ACCOUNT NUMBER ______________________________________________________   DATE ___________________________________




           ADDRESS ___________________________________________________________________________________________________________
           CITY/STATE/ZIP _____________________________________________________________________________________________________

           PHONE ______________________________   FAX ___________________________  EMAIL ______________________________________
           If reordering a custom standard please provide Part# or Quote# ________________________________________________

                                                         EPA METHOD




                   ANALYTE                CATALOG #                       CAS#               CONCENTRATION


            1.          ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

            2.    ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

            3.    ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
            4.    ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

            5.          ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
            6.          ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

            7.    ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

            8.    ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
            9.    ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

           10.    ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

           11.          ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
           12.          ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
           13.          ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

           14.    ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

           15.    ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

           16.    ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

           17.    ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
           18.          ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
           19.    ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

           20.          ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

           21.    ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

           22.    ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
       TOTAL # OF ANALYTES: __________
       DESIRED CONCENTRATION AND SOLVENT: _______________________________________________________________________
       VOLUME (check one): 1mL______  2mL______  5mL______  10mL_______  Other_________  # of Units: ______________________
       MSDS provided with all standards.          Amber Ampules used unless specifi ed otherwise: _____________________________
       DOCUMENTATION (check one):
       ❑  Gravimetric Certifi cation: Guarantees the analytes in the custom standard to be made within ± 5% of specifi cations.

       ❑ Quantitative Certifi cation: Includes verifi cation of the concentration and peak identifi cation.
       All mixtures are prepared in accordance with our ISO 9001 & ISO 17025 registration. All analytes are certifi ed >/= 98% unless noted. Corrections are made to 100% purity.

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