Form Code LID-FORM-03.3 Page No.

Page 1 of 1
Revision No. 00
Reference No.
Effectivity Date 15 January 2024
Reservation and Release of Materials and Equipment Form

Reminders: The requesting laboratory faculty shall write all the materials and equipment needed in the experiment. We shall not provide
additional materials and equipment on the day of the experiment. The reservation shall be done three (3) working days prior to the
conduct of the experiment. Please accomplish this form in triplicate (requesting laboratory faculty, LID office, and student).

To be accomplished by the requesting laboratory faculty:

Program: B S P s y c h o l o g y Grade/Year Level and Section/Block: 1 and 2

Subject/Course Code: CHEM 203.1 Subject/Course Description: ORGANIC CHEMISTRY
Title: Simple and Fractional Distillation Activity No.: 1

No. of Date Name of Signature of

Schedule Day/Time
Groups Needed Requesting Instructor Requesting Instructor
Monday-Tuesday/ 7:30-10:30 5 February 5-6, 2024
Monday-Tuesday/ 12:00-3:00 5 February 5-6, 2024 ANGELICA A. CABRIA

Qty. Needed Equipment/Materials/ Trademark/ Qty. Needed Equipment/Materials/ Trademark/

per group Supplies/ Specification per group Supplies/ Specification
12 Test tubes 0.5 ml calibration
12 Boiling stones
1 Hot plate
1 Thermometer
1 Quick fit distilling flask
1 Iron stand
1 Iron clamp
6 Dropper
2 Watch glass
1 box Match stick
1 Graduated cylinder 10 ml

*The requesting laboratory faculty shall receive feedback from LID staff on the availability of requested materials and equipment within one (1) working day upon
submission in the lab unit.

To be accomplished by the LID staff:

Received by: Date:

(Signature over printed name)

Returned to: Date:

(Signature over printed name)

To be accomplished by the borrower:

Released to: Date:

(Signature over printed name)