Page 305 - Chem Service 2016 Catalogue

Custom Solutions and Mixture Form
Custom Solutions and Mixture Form

Request Form CUSTOMER NAME ______________________________________ COMPANY NAME _________________________________________
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. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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8. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
9. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

10. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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14. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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16. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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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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