Free 0431e - Federal

INDUSTRIAL CHEMICALS WORKSHEET
3. SEALS INTACT NONE BROKEN 7. DESCRIPTION OF SAMPLE

1. PRODUCT

2. SAMPLE NUMBER

4. DATE REC'D

5. RECIEVED FROM

6. DISTRICT OR LABORATORY

8.

NET CONTENTS

NOT APPLICABLE NOT DETERMINED

DECLARED UNIT SEE PAGE

9.

LABELING

ORIGINAL (S) SUBMITTED COPIES SUBMITTED NONE

10. SUMMARY OF ANALYSIS a. METHOD Pesticide Analytical Manual, Vol. I (Insert revision date) 211.13 ( 212.13 ( ) __________, 211.14 ( ) ___________, ) __________ 232.3___________ 232.4 ___________ 212.2 ___________

211.14 d, 6% ___________ 15% ___________ 50%___________ 252.13, 1 ___________ 2 ___________ 3 ____________ _______________________________________________________ b. SAMPLE PREPARTION & COMPOSITE (Reference/Describe ) REC'D PREPARED

c. RESULTS RESIDUES Dect Mode

QUANTITATION (PPM)

CONFIRMATION (Brief description and reference)

}

EC

MC

ELC

FPO

N/P

KCLTD

d. ADDITIONAL INFORMATION

11. RESERVE SAMPLE

12. a. ANALYST SIGNATURE (Broke Seal

)

d.

13. WORKSHEET CHECK

a. BY

b.

e.

b. DATE

c.

f.

14. DATE REPT

FORM FDA 431e (3/80)

PREVIOUS EDITION IS OBSOLETE

ATTACH. ____ - ____

PAGE

OF

PAGES
EF

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