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CafSUfin
coar Laborabriss
JAKARTA
,
aSKRINDO Eluilding.7 th
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690425.
6540418
Fac.irr*e
021
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BAIJARBARU
:
Jl. A. Yani
KM.
2l,e
LandaBan Ulh Bcnjarb.ru
Phone
i051'1
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S.Maa : Andylical ard T.Cing
Lrbo?rtory @iault
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0541
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Pengguna
Jasa
.4pplicanr
r\lamat
Penguuna
Jasa
,4ddre
s,s
of'.4 p I i cant
Lokasi
Sample
fvnple Incar.ion
Jumlah
Sampel
.4mtrunr
ol
lamplc
-
Dengan
ini
mengajukan
permintaan
untuk
pengujian/analisis
sebagai
berikut :
A.fiirm
to he onler
a
sample te.st
or
analysis
of
FORMULIR
PERMINTAAN
PENGUJIAN
Form
of
Sanple
Tesl
Order
Nomor Sertifikat
Certifikat
No.
No.
Laboratori
um
Laboralory
No.
I\aruindo
Eqru [quuq
pou-I\n
r uq$
Pemegan
Applicott,
FIe/a201lFM
I
,.rr.7..1 -r.:'.*,
..
No.
Kode
Sampel
(-rxle
of
somple
Parameter Pengujian
Dpe
of
Test
Metode
Uji
Standart
Methd
Biaya
per parameter
Cost
of
Type
\
't{,4
rb,/v^
lt6
't ,,
\w,,
Aah
,
\ltn,fc,ts.
SU,t\61
l+s'fM
Catatan
.i
Note
Pengujian
selesai
tgl.
Ihe
test completed
on
Jumlah
Biaya/total
Cost
Rp.
\
ono
ooor
Umg
Muka/Down
Payment
Rp.
Biava
vans
harus dilunasi
RD.
Cost to be
payed
Rp
Penerima.
*g Mer
ilL
art
Received h1,,
