PT.

Intertek Utama Services

Cilandak Commercial Estate
Building 103E
Jl. Cilandak KKO
Jakarta 12560 Indonesia
Phone: 021 780 8011
Fax: 021 780 7929
SAMPLE SUBMISSION FORM

Client Order No : 7001 Submitted by: Yoga Herlambang Project : Sekadau

Report to: h3rlambank99@gmail.com

SENDER: Courier: Rented Car

Con. Note / AWB: ………………………..

Indo Geo Info
Sepakat 2, Bansir Darat, Pontianak Copy to :
Originating from Kalimantan Barat
Tenggara, Pontianak, Kalimantan
Barat
No. of packages: One (1) bags
Invoice to: h3rlambank99@gmail.com
Phone: + 62 815 78899124
No. of samples: 1(one)
Email: h3rlambank99@gmail.com
Security Tag No: KS001

Sample Numbers Sample Instructions / Elements Method of

Type Concentration Ranges Analysis

Au FA50/AA

111010044 ROCK Analisys All elements 4AH2/OE201

Cu AS/AA

Zn ZN1/VOL

Preparation Schemes

PT – Total Preparation: Dry, crush, pulverize entire sample to 90% passing 200#.

PB – Basic Preparation: Dry, crush, split, pulverize <1.5 Kg to 90% passing 200#, retain coarse residue.

PS – Soil Preparation: Dry, pulverize < 1.5 Kg to 90% passing 200#.

Other - As per client instructions _________________________________________________________________________________________

Sample Security Checklist

1. Box and Padlock Secure Sender: (Box should be checked) Receiver:

2. Numbered tags are correct Sender: (Box should be checked) Receiver:

Signed: Sender Yoga H ______________ Date: 31/03/2022 ___________________

Courier _________________________ Date: _____________________________
Prep _________________________ Date: _____________________________