Appendix II – 1
Republic of the Philippines
OFFICE OF THE DISTRICT ENGINEER
Masbate II D.E.O
Dimasalang, Masbate
SAMPLE CARD (For Government Project)
Project :
______________________________________________________________
(Name) (City/Province)
Kind of material :______________________________________________________________
Sample identification :______________________________________________________________
Quantity represented :______________________________________________________________
Sampled at :______________________________________________________________
(Give accurate location possible)
Original Source :______________________________________________________________
Owner / Supplier :______________________________________________________________
Sampled by :________________________ _____________________ ________________
(Name & Designation) (Office) (Date)/ Signature
:________________________ _____________________ ________________
(Name & Designation) (Office) (Date)/Signature
Proposed use :______________________________________________________________
Test desired :______________________________________________________________
Governing Specification :_______________________________________________________________
Shipped by :________________________ _____________________ _______________
(Name & Designation) (Office) (Date)/Signature
:_______________________ _____________________ ________________
(Name & Designation) (Office) (Date)/Signature
Send Test Results to :______________________________________________________________
______________________________________________________________
(Mailing Address)
REMARKS :______________________________________________________________
Bill charged to :______________________________________________________________
Submitted by :___________________________________ __________________________
(Name) (Signature)
____________________________ __________________________________
(Office) (Mailing Address)
- - - -- - - -- - - -- - - -- - - -- - - -- - - -- - - -- - - -- - - -- - - -- - - -- - - -- - - -- - - -- - - -- - - -- - - -- - - -- - - -- - - -- - - -- -
Received by: ________________________________ Lab. No. :_______________________