Free 0431m - Federal

ELEMENTAL ANALYSIS WORKSHEET
3. SEALS NONE INTACT BROKEN

1. PRODUCT

2. SAMPLE NUMBER

4. DATE REC'D

5. RECIEVED FROM

6. DISTRICT OR LABORATORY

7. DESCRIPTION OF SAMPLE

8.

NET CONTENTS

NOT APPLICABLE NOT DETERMINED __ UNITS EXAMINED

DECLARED UNIT AMOUNT FOUND % OF DECLARED

9. LABELING NONE

ORIGINAL (S) SUBMITTED COPIES SUBMITTED

10. SUMMARY OF ANALYSIS CONTAINER: PRODUCT: CODE: a. METHOD AOAC b. SAMPLE PREPARTION & COMPOSITE (Reference/Date)

REC'D PREPARED

c. SUB

RESULTS ELEMENT ATOMIC ABSORP. ELECTRO

QUANTITATION (PPM) PHOTOMETRIC

d. ADDITIONAL INFORMATION

11. RESERVE SAMPLE

12. a. ANALYST SIGNATURE (Broke Seal b. c.

)

d.

13. WORKSHEET CHECK

a. BY

e. f.

b. DATE

14. DATE REPORTED PAGE OF PAGES
EF

FORM FDA 431m (12/79)

PREVIOUS EDITION IS OBSOLETE

ATTACH. ____ - ____

Created by: PSC Media Arts (301) 443-2454