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8213 – 19 Ave NW
Edmonton, AB, T6K 2C9
Ph (780) 462-2231 Fax (780) 490-0472
Email info@aircheklab.ca
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HIGH
PRESSURE SAMPLING (ABOVE 2215 PSIG)
USING A CUSTOMER
BREATHING AIR CYLINDER
Complete ALL the following information
FOR BILLING & SHIPPING:
Company
_________________________________________________________ Date ______________________
Contact Person
______________________________________________ Phone ___________________________
Email
______________________________________________________ Fax
_____________________________
Purchase Order #
__________________________________________ Results & Invoice: fax ____ OR
email ____
Shipping Address _____________________________________________________________________________
City
_______________________________ Prov _________ Postal Code
_________________________
Billing Address
same ____ or ___________________________________________________________________
City
________________________________ Prov _________ Postal Code
_________________________
Preferred
Courier_____________________________________ Account
#________________________________
FOR CERTIFICATE:
Company same ____
or ________________________________________________________________________
Compressor Brand
___________________________________ Serial # ___________________________________
Sampling Location _________________________________
I,
_______________________________ certify that the supplied breathing air sample
submitted in
(Print name)
Cylinder #
________________ at _________ psig was produced by the above compressor /
serial# / location.
Signature _________________________________________
NOTE: Oil, particulate & condensate
test has not been requested.
All tanks must be LABELLED with the
COMPANY NAME. All air tanks sent by courier or transport MUST BE
PACKAGED OR CRATED along with the following …
Ø The box, package or
crate (max 10 kg) must be marked with the words “TEST SAMPLES” at
least 25 mm high and displayed against a background of contrasting colour.
Ø A shipping
document with the name & address of the consignor and the words “TEST
SAMPLES”
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