fastfacts07 - page 51

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Custom Reference Materials Request Form
DomesticCustomers
FAX#: (814) 355-2895
email: standards@restekcorp.com
ALLmixtures are produced in accordancewith our ISO 9001 registration.
Analytical balances are calibrated daily at sevenmass levels usingNIST traceableweights.
ALL rawmaterials used are aminimum of 97% pure unless otherwise specified.
International Customers
ContactYourLocal
RestekRepresentative.
Take these eight steps tocreate the rightsolution:
1. MixtureDescription:____________________________________________________________________________________
2. Solvent: ______________________________________________________________________________________________
3. Number of Components: ________
4. Volumeper ampul (select): 1mL, 2mL, 5mL, 10mLor other ______mL
5. Quantityof ampuls: ________
6. Testinganddocumentation that bestmeets your requirements:
❍ GravimetricDocumentation: Lot Sheetwithbalanceprintout attached.
❍ QualitativeDocumentation: Certificateof Composition, Chromatogram, andGravimetricDocumentation.
❍ QuantitativeDocumentation: Certificateof Analysis andDataPack.
7. Compound(s): (list or attach sheet; includeCASnumber)
Compound01: ______________________________________________________________ Concentration:________________________________
Compound02: ______________________________________________________________ Concentration:________________________________
Compound03: ______________________________________________________________ Concentration:________________________________
Compound04: ______________________________________________________________ Concentration:________________________________
Compound05: ______________________________________________________________ Concentration:________________________________
Compound06: ______________________________________________________________ Concentration:________________________________
Compound07: ______________________________________________________________ Concentration:________________________________
Compound08: ______________________________________________________________ Concentration:________________________________
Compound09: ______________________________________________________________ Concentration:________________________________
Compound10: ______________________________________________________________ Concentration:________________________________
Compound11: ______________________________________________________________ Concentration:________________________________
Compound12: ______________________________________________________________ Concentration:________________________________
Compound13: ______________________________________________________________ Concentration:________________________________
Compound14: ______________________________________________________________ Concentration:________________________________
Compound15: ______________________________________________________________ Concentration:________________________________
Compound16: ______________________________________________________________ Concentration:________________________________
Compound17: ______________________________________________________________ Concentration:________________________________
Compound18: ______________________________________________________________ Concentration:________________________________
Compound19: ______________________________________________________________ Concentration:________________________________
Compound20: ______________________________________________________________ Concentration:________________________________
8. ConcentrationUnits
❍ mg/mL ❍ µg/mL ______________________________________________❍ ng/mL ❍ vol./wt.% ________________❍ wt./wt.% ❍ other
Contact Information:
Name: ____________________________________________________________ Date: __________________________
Company/Location: ______________________________________________________________________________________
______________________________________________________________________________________________________
Phone#:__________________________________________ FAX#: ____________________________________________
E-mail: ________________________________________________________________________________________________
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