restek-tnx14 - page 340

FOODS, FLAVORS, & FRAGRANCES
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Phone: 800-356-1688 or 814-353-1300
www.restek.com
Custom Reference Materials Request Form
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: ________________________________________________________________________________________________
U.S. Customers
FAX#: (814) 355-2895
email: standards@restekcorp.com
online form: www.restek.com
ALLmixtures are produced in accordancewith our ISO 9001:2000 registration.
Analytical balances are calibrated daily at sevenmass levels usingNIST traceableweights.
ALL rawmaterials used are aminimum of 97% pure unless otherwise specified.
International Customers
ContactYour
RestekRepresentative.