<p> SteriPro Labs Residual Sample Submittal Form 1500 W. Thorndale Av, Itasca, IL 60143 Phone: 630-285-9121 Fax: 630-467-0960</p><p>James Watt No. 22 Parque Industrial Cuamatla Cuautitlan Izcalli, Estado de Mexico 54730 Phone: (0115255) 26209060 Fax: (0115255) 58703246</p><p>SEND REPORT TO: SEND INVOICE TO: Same as report Address below Company: Company: Address: Address: City/State: City/State: Zip/Country: Zip/Country: Contact Name: Attention: Phone No (Ext): Fax Number: PO NUMBER * Email (required): (REQUIRED FOR ALL TESTING):</p><p>* NOTE: All Test Reports will be scanned via email. If Hard Copies are desired ($10 charge will apply), please specify: FAX MAIL</p><p>TURN TIME: STANDARD EXPEDITE – ADDITIONAL FEE (CALL LAB FOR TIMELINE AND PRICING) PRODUCT HAZARDS: NONE YES - ATTACH APPROPRIATE MSDS (REQUIRED FOR ALL LIQUIDS AND POWDERS) **RETURN SAMPLES: NO YES – Provide FedEx/UPS # for Shipping: **NOTE: RESIDUAL TESTING IS DESTRUCTIVE….PLEASE CALL AHEAD TO MAKE ARRANGEMENTS WITH THE LAB</p><p>REQUIRED INFORMATION FOR SAMPLE SUBMITTED FOR TESTING (PLEASE USE ONE FORM PER PRODUCT NAME AND FOR EACH TEST METHOD)</p><p>PRODUCT NAME: NUMBER OF SAMPLES: PART NUMBER (IF PERTINENT): LOT / BATCH NUMBER (IF PERTINENT): SHIPPING CONDITIONS: Dry Ice Ice Packs Ambient SPECIFIY STORAGE CONDITIONS, UPON RECEIPT: Frozen Refrigeration Ambient</p><p>***************IF PERTINENT TO THE TESTING, PLEASE PROVIDE THE FOLLOWING INFORMATION*************** Sterigenics Sterilization Plant: Cycle Type: Half Full Times Sterilized: 1X 2X Other: Process Number: Date Processed: Protocol Number: Consultant Name / Study Director: SteriPro Labs Test Specification # (if applicable): Amount Of Aeration To Which Samples Were Exposed (if applicable) – Please List Below: Ambient Total Time Heated Total Time</p><p>Other Testing: Document N°: AM-F-LB-283 Revision N°: 2 User must verify the revision number of printed or downloaded document against the effective version. Confidential Information Page 1 of 2</p><p>SteriPro Labs Residual Sample Submittal Form 1500 W. Thorndale Av, Itasca, IL 60143 Phone: 630-285-9121 Fax: 630-467-0960</p><p>James Watt No. 22 Parque Industrial Cuamatla Cuautitlan Izcalli, Estado de Mexico 54730 Phone: (0115255) 26209060 Fax: (0115255) 58703246</p><p>EXOTHERMIC TESTING – ITASCA ONLY FOR STERIPRO LAB USE ONLY</p><p># of Samples Received: ______Samples received on: Dry Ice Ice Packs Ambient</p><p>Verified By/Date:______Customer #: WO#: SO#:</p><p>Comments and/or Special Instructions:</p><p>Customer Signature: ______Date: ______(REQUIRED for Testing)</p><p>Document N°: AM-F-LB-283 Revision N°: 2 User must verify the revision number of printed or downloaded document against the effective version. Confidential Information Page 2 of 2</p>