Jensen Technologies, LLC
15985 South Golden Road, Unit H, Golden, CO 80401
Cell: 303-478-3929 Fax: 720-542-542
e-mail: Jensen.tech@comcast.net
website: www.jensentechnologiesllc.com
Sample Submission and Authorization Form Page 1 of __
Please include this form with samples (please print)
Company Information (or Attach a Business Card)
Company name:______________________________________
Address:____________________________________ State ____ Zip ___________
Telephone:_______________ Fax:_______________________
e-mail:________________________
Report To: __________________________________________
Report: via: e-mail / Fax / Mail (Circle)
Project No:___________________
Project Name:________________________________________
PO No:________________________
Date Results Required:____________________
Disposition of Samples After Analysis: Discard __ Return __ Forward __
WORK REQUEST Cost $
Number of Samples: ___________ (on this page) Date Rcvd: ___/___/___
Sample Type: R=Rock;CR=Core;W=Wastewater - Water
PW=Produced Water;S=Soil;PPT=Precipitate;CONC=Concentrate;
PERM=Permeate;SL=Sludge;SED=Sediment;O=Other(Specify)
SPECIAL INSTRUCTIONS:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
Authorization Signature: _______________________________
Date: ______________
15985 South Golden Road, Unit H, Golden, CO 80401
Cell: 303-478-3929 Fax: 720-542-542
e-mail: Jensen.tech@comcast.net
website: www.jensentechnologiesllc.com
Sample Submission and Authorization Form Page 1 of __
Please include this form with samples (please print)
Company Information (or Attach a Business Card)
Company name:______________________________________
Address:____________________________________ State ____ Zip ___________
Telephone:_______________ Fax:_______________________
e-mail:________________________
Report To: __________________________________________
Report: via: e-mail / Fax / Mail (Circle)
Project No:___________________
Project Name:________________________________________
PO No:________________________
Date Results Required:____________________
Disposition of Samples After Analysis: Discard __ Return __ Forward __
WORK REQUEST Cost $
Number of Samples: ___________ (on this page) Date Rcvd: ___/___/___
Sample Type: R=Rock;CR=Core;W=Wastewater - Water
PW=Produced Water;S=Soil;PPT=Precipitate;CONC=Concentrate;
PERM=Permeate;SL=Sludge;SED=Sediment;O=Other(Specify)
SPECIAL INSTRUCTIONS:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
Authorization Signature: _______________________________
Date: ______________
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