‫‪F12‬‬

‫ﺗﻘﺮﻳﺮ اﻟﻔﺤﺺ اﻟﻈﺎﻫﺮى ﻟﻠﻤﻮاد اﻟﻜﻴﻤﺎوﻳﻪ واﻟﻤﻄﻬﺮات‬

‫اﻟﺘﺎرﻳﺦ ‪٢٠....../......./...... :‬‬ ‫‪.....................‬‬ ‫رﻗﻢ اﻣﺮ اﻟﺘﻮرﻳﺪ ‪:‬‬

‫اﻟﻜﻤﻴﺔ ‪..................... :‬‬ ‫‪..................... :‬‬ ‫اﻟﺨﺎﻣﺔ‬
‫اﻟﻤﻮرد ‪..................... :‬‬ ‫‪..................... :‬‬ ‫ﺣﺠﻢ اﻟﻌﻴﻨﺔ‬

‫ﻧﺘﻴﺠﺔ اﻟﻔﺤﺺ‬ ‫ﻧﻘﻄﺔ اﻟﺘﻔﺘﻴﺶ‬ ‫م‬

‫ارﻗﺎم اﻟﺒﺎﺗﺸﺎت‬ ‫‪١‬‬

‫ﺗﺎرﻳﺦ اﻻﻧﺘﺎج‬ ‫‪٢‬‬

‫ﺗﺎرﻳﺦ اﻟﺼﻼﺣﻴﺔ‬ ‫‪٣‬‬

‫اﻟﺼﻔﺎت اﻟﻈﺎﻫﺮﻳﺔ‬
‫‪٤‬‬
‫ﻟﻠﻤﺎدة‬

‫ﻣﻼﺣﻈﺎت ‪:‬‬

‫اﻟﻨﺘﻴﺤﺔ ﻃﺒﻘﺎ ﻟﻺﺧﺘﺒﺎرات ‪:‬‬

‫ﻣﻘﺒﻮل ﺑﺎﻟﺨﺼﻢ‬ ‫ﻣﺮﻓﻮض‬ ‫ﻣﻘﺒﻮل‬

‫ﻧﺴﺒﺔ اﻟﺨﺼﻢ ‪%.........‬‬

‫اﻟﻘﺎﺋﻢ ﺑﺎﻟﻔﺤﺺ ‪................................. :‬‬

‫رﺋﻴﺲ اﻟﻘﺴﻢ ‪..................................... :‬‬