MY CO2 LABORATORY ANALYSIS REQUEST FORM Form : 49(02) Company: From : (Dato / Dr / Mr / Ms / Mdm) Address: Tel No.: Fax No.: E-mail: Date : Attn to MY CO2 Laboratory PIC : (Mr / Ms) Sample description : Sample Name / Marking : Nutrition facts: Heavy Metals: Minerals: Preservatives: Vitamins: M'sia Arsenic Sodium Benzoic acid A K US Mercury Potassium Sodium benzoate B1 Australia Lead Calcium Sorbic acid B2 Singapore Cadmium Magnesium Potassium dioxide B3 China Tin Iron Sulphur dioxide B5 Hong Kong Antimony Zinc Nitrate B6 Taiwan Copper Phosphorus Nitrite B12 Zinc Iodine Propionic acid C Colour Manganese Boric Acid D Colouring Amino Acid Sodium Chloride Sodium Nitrite E Anitibiotics / Drug : Sugars : Artificial sweetener : Dyes : Microbiology : Chloramphenicol Total sugars Saccharin Sudan I TPC Nitrofurans AOZ Brix value Cyclamate Sudan II Coliform Nitrofurans AMOZ Sugar profile Sudan III E-coli Nitrofurans SEM Fructose Pesticides : Sudan IV Yeast & mould Nitrofurans DHA Glucose Organochlorine Para Red Step. Aureus Oxy / Tetracycline Sucrose Organophosphorus R2G Salmonelia Beta agonists Maltose Melachite Green P. asruginosa Tylosin Maltotriose Water : Bacillus cereus Colistin Sulphate Lactose MOH Drinking Water Toxin : C perfringerns Amoxicillin 25th Schedule Aflatoxin V cholerea Histamine Toy : T2 Toxin V parahaemolyticus Fluroquinolones Part 1 Waste Water : DON Enterobacteria Benzo(a)pyrene Part 2 DOE std 5 Fumonisin Listeria Melamine Part 3 DOE std 32 Ochratoxin Legionellaceae Gentamicin Part 7 DOE std 23 Zearelenone Thermophilic Bacteria Nutrient : Edible Oil : Fertilizer : Other : Protein FFA Nitrogen Fat IV Phosphorus Fibre PV Potassium Moisture Sap value pH Ash M & I Humic Acid Tran Fat Slip melting p MgO Monounsaturated F Unsap value CaO Polyunsaturated F Colour Zinc Satured Fat Refractive index Copper EPA DOBI Silica DHA Flash Point Moisture En / Carbohydrate Cloud Point Boron PO No.: Quotation No.: Remarks : Other specific Composite sample *** Email/Fax result first Scan me result instruction / COA collect by Hand COA send by Hand / Normal Post / Courier request : COA include photo COA colour print COA additional ( ) copies COA Mfg/Exp date Return the sample Return bottle / container / icebox Invoice include PO no. Result calculate in _______________ (eg: g / ppm / %w/w) Start analysis date on (F1)______________ (F2)_______________ (F3) ______________ Retest Sample Call me when result ready Invoice / COA to : ___________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ NOTE : All special request subject to the additional charges, you may email your request to [email protected] *** DENOTE SUBJECT APPROVAL Signature and Chop / IC No. FOR MY CO2 OFFICE USED ONLY Sample Received Date : Sample Condition : Fine / Not Fine Authorized Signature :.