ANALYTICAL SERVICES REQUEST FORM

INSTRUCTIONS: Use one form for each sample or group of similar samples

requiring the same analyses. Check the box for each service / analysis

required and fill in the expected values and units of the analytes of interest.

Fill in the form as completely as possible. Use reverse side if needed.

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Sample #(s): _________________________________________________

Sample Description/Matrix: (IMPORTANT!)

m.p. ____°C b.p. ____°C Hygroscopic Y / N Hazardous Y / N

Soluble in___________ Sensitive to_________ Explosive Y / N

All samples will be returned† unless marked for municipal disposal.

� Return Sample � I certify that samples can be disposed of inmunicipal waste system.

SERVICE MICROANALYSIS Expected WATER Expected METALS Expected METALS Expected

� Standard Value % ANALYSIS Value mg/l M Value/Units ((CONT) Value/Units

� Priority† (~5 working days) � Carbon ______ � Acidity ______ � Aluminum* _______ � Rhodium _______

� High Priority† (~2 working days) � Hydrogen ______ � Alkalinity, Total ______ � Antimony* _______ � Rubidium _______

Check for availability of priority � Nitrogen (Dumas) ______ � OH-, CO3=, HCO3

- ______ � Arsenic* _______ � Ruthenium _______

services prior to submittal. � Nitrogen (Kjeldahl) ______ � Bromide ______ � Barium* _______ � Samarium _______

REPORT RESULTS � Oxygen ______ � Carbon Dioxide ______ � Beryllium* _______ � Scandium _______

� As Received � Oxygen (Merz) ______ � Chloride ______ � Bismuth _______ � Selenium* _______

� Dry Wt. Basis � Sulfur ______ � Conductivity ______ � Boron* _______ � Silicon* _______

� Other Halogens � Fluoride ______ � Bromine _______ � Silver* _______

_______________________________ � Fluorine ______ � Iodide ______ � Cadmium* _______ � Sodium* _______

_______________________________ � Chlorine ______ � N-Ammonia ______ � Calcium* _______ � Strontium* _______

QA/QC REPORTING � Bromine ______ � N-Nitrate ______ � Cerium _______ � Sulfur _______

� Raw Data with associated QC† � Iodine ______ � N-Nitrite ______ � Cesium _______ � Tantalum _______

� Other � Ash ______ � N-TKN ______ � Chromium* _______ � Tellurium _______

________________________________ � Dry � pH ______ � Cobalt* _______ � Terbium _______

_______________________________ � Sulfated � o-Phosphate ______ � Copper* _______ � Thallium* _______

SAMPLE PREP† � Carbonate Carbon ______ � P-Total ______ � Dysprosium _______ � Thorium _______

� Grind � TOC (difference) ______ � Silica, Dissolved ______ � Erbium _______ � Thulium _______

� Homogenize � TOC (acidification) ______ � Solids-TDS ______ � Europium _______ � Tin* _______

� Filter COAL / BIOMASS Expected � Solids-TSS ______ � Gadolinium _______ � Titanium* _______

� Extract in ____________________ ANALYSIS Value % � Solids-TS ______ � Gallium _______ � Tungsten _______

� Dry � Ash ______ � Solids-TVS ______ � Germanium _______ � Uranium _______

� Temp ____________°C � Ash Analysis � S-Sulfate ______ � Gold _______ � Vanadium* _______

� Vacuum† or � Air � BTU ______ � S-Sulfide ______ � Hafnium _______ � Ytterbium _______

� for ______ hours � Carbon Dioxide ______ � S-Sulfite ______ � Holmium _______ � Yttrium _______

� Constant Weight† � Moisture ______ � S-Thiosulfate ______ � Indium _______ � Zinc* _______

� Report Weight Loss† � Proximate � S-Total ______ � Iodine _______ � Zirconium _______

� Other Instructions � Sulfur ______ � Thiocyanate ______ � Iridium _______ *Included in ICP-AES Scan

_______________________________ � Sulfur Forms � Turbidity ______ � Iron* _______ ICP SCANS

_______________________________ � Ultimate � UV absorbance ______ � Lanthanum _______ � ICP-AES Scan(~30 elements)

SAMPLE HANDLING � Direct Oxygen OTHER Expected � Lead* _______ � ICP-MS Scan(~60 elements)

� Handle Under N2† � Oxygen by Difference Value/Units � Lithium* _______ � ICP-MS and -AES Scan

� Store at 4°C ORGANIC CARBON Expected � Nitrogen � Lutetium _______ ION CHROMATOGRAPHY

� Store in Freezer ANALYSIS Value/Units (chemiluminescence)_____ � Magnesium* _______ � Anion Scan

Special Instructions � DOC ______ � Nitrogen, Basic _____ � Manganese* _______ � Specific Ions – select from

_______________________________ � TOC ______ � Free Sulfur _____ � Mercury _______ WATER ANALYSIS or specify

_______________________________ � TC ______ � Calorimetry (BTU) _____ � Molybdenum* _______ below _______________________________ � Density _____ � Neodymium _______ ______________________________ _______________________________ � Flash Point _____ � Nickel* _______ Other

_______________________________ � Melt Point _____ � Niobium _______ ______________________________

_______________________________ � Mole Wt. (VPO) _____ � Osmium _______ ______________________________

_______________________________ � 1 point � 4 point � Palladium _______ ______________________________

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ORGANIC HALOGEN Expected

Solvent ______________ � Phosphorus* _______ ______________________________

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ANALYSIS Value/Units

� Water (Karl Fischer) _____ � Platinum _______ ______________________________

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� TOX (water) ______

� Other (list) � Potassium* _______ ______________________________

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� EOX (solid) ______

_________________________ � Praseodymium _______ ______________________________

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� TX ______

_________________________ � Rhenium _______ ______________________________

†Indicates additional charge ���� Please check box if you have provided more information on reverse side. rev. 7/2017

Client Name _________________________________ Company __________________________________ Address ____________________________________

_________________________________________Phone ____________________________________ E-mail ____________________________________ Billing Name _______________________________Billing Company _____________________________ Billing Address _____________________________

_________________________________________Billing Phone ________________________________Billing E-mail ________________________________

Payment Cash Check Credit Card (call with info) PO #_____________________________