Sample Type
e.g. air, water, meat,
surface wipe, etc.
e.g. RX-112233 Water N/A Purified Water Sample
IEH Lab Sample #
IEH Use Only
Completed and signed sample submission form indicates agreement with IEH terms and conditions and authorizes IEH to
perform the requested test(s). To protect the confidentiality of customer information, IEH will only include a unique
Customer ID and Job ID on final reports instead of the customer name and address.
Please check preferred option(s) for receiving results (Electronic documents will be provided in Adobe Acrobat (PDF) format).
Customer Information
Technical Contact:
Invoicing Contact:
Fax to:
Company Name:
Submitted By (print):
Customer Special Instructions:
Write below as you want them to appear on the final
report (Please use separate sheet if you would like to provide
additional information about your samples).
Item #
* Emergency Services require prior notification and sample arrival by 9:00 AM PST, Mon - Sat. Please call our Service Representative at 206-522-5432 for more information regarding turn around time, price and other conditions.
** Definitions for abbreviations: APC=Aerobic Plate Count (Total Plate Count); TCC=Total Coliform Count; ECC=Coliform/E. coli Count; LAB=Lactic Acid Bacteria Count; AnPC=Anaerobic Plate Count; PSYCH=Aerobic Psychotrophic
Count; AnPSYCH=Anaerobic Psychotrophic Count; Y&M=Yeast & Mold Count; ST Total =SporeTrap (Zefon or equiv.) Total Dust; ST Fungi=Spore Trap (Zefon or Equiv.) Fungi only; Viable Fungi=Viable Fungi (2 STD Media Bulk or
Swab); Env. Bact=Envir. Bacteria, 30°C Incu.; Ent. Bact=Entero Bacteria, 37°C Incu; ECO157=E. coli O157:H7 Detection; Salm=Salmonella spp. Detection; List=Listeria spp. detection and Lm=L. monocytogenes detection.
Authorized Signature:
Page of
Street Address:
City, State, Zip:
Purchase Order #:
IEH Sample Submission Form
E-mail to:
(as applicable)
Turn around time requested*: Routine Expedited Emergency
Analyses Requested**
e.g. Quantitative Tests (QNT) : APC; TCC; ECC; LAB; AnPC; PSYCH;
AnPSYCH; Y&M; ST Total; ST Fungi; Viable Fungi; Env. Bact; Ent. Bact,
Qualitative Tests (QL): ECO157; Salm; List; Lm, Other (describe)
Sample Condition: Frozen Refrigerated Other (describe): Date/Time Sample(s) Shipped:
Customer ID #: Job ID # / IEH Project #: File Name / Sample Set #:
Authorized Signature:
IEH Special Instructions/ Customer Follow up:
Received By (print):
Send Results to IEH Project Manager: Due Date/Time: Date/Time Received:
Laboratories & Consulting Group
15300 Bothell Way NE, Lake Forest Park, WA 98155 | P 206.522.5432 | F 206.306.8883 | info@iehinc.com | www.iehinc.com
IEH Sample Submission Form © 2006 5/25/2006
click to sign
click to edit