METRO MANILA SUBWAY PROJECT PHASE 1

PACKAGE CP104: TWO UNDERGROUND STATIONS

(ORTIGAS AND SHAW BOULEVARD STATION) AND TUNNEL
Contractor The Engineer Client

SAMPLE CARD

Project Name : METRO MANILA SUBWAY PROJECT PHASE 1 - CP104: TWO UNDERGROUND STATIONS
(ORTIGAS AND SHAW BOULEVARD STATION) AND TUNNEL
Sample ID : MMSP104-FLA-SEC-001
RIN Reference No. : MMSP104-RIN-QC-00007

Kind of Material : Flyash Type F

Qty. Representative :
Sampled at : : Baragay San Rafael, Calaca, Batangas, 4212
(Give Accurate Location as Possible)

Original Source : :
Owner/ Supplier : : Sem-Calaca Power Corporation

Proposed Use : Prequalification

Test Desired: : Quality Test

Specifications : : Technical Specification

Bill Charge to : :
Send Test Result to : : Tokyu-Tobishima-Megawide Joint Venture (TTM-JV)
(Name of Company)

:
(Mailing address)

Remarks : :
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Sampled / Cast by : :

(Name) (Designation) (Signature) (Office) (Date)

Witnessed by : :

(Name) (Designation) (Signature) (Office) (Date)

(Name) (Designation) (Signature) (Office) (Date)

(Name) (Designation) (Signature) (Office) (Date)

(Name) (Designation) (Signature) (Office) (Date)

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Submitted by : :

(Name) (Designation) (Signature) (Office) (Date)

Witnessed by : :

(Name) (Designation) (Signature) (Office) (Date)

(Name) (Designation) (Signature) (Office) (Date)

(Name) (Designation) (Signature) (Office) (Date)

(Name) (Designation) (Signature) (Office) (Date)

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Received by :
(Name) (Designation) (Signature) (Office) (Date)

Due Date : Lab. No. :

Sample Card No. :

O.R. No. :