www.esr.cri.nz
NATIONAL CENTRE FOR RADIATION SCIENCE
LABORATORY SERVICES REQUEST FORM
TESTING OF FOODSTUFFS
CONTACT DETAILS
ANALYSIS DETAILS
SAMPLE DETAILS
All information provided in this section will be exactly duplicated on the test report. Minimum quantity for gamma analysis
is 500g per item and for alpha spectrometry or beta counting 100g per item. Please contact ESR if quantity to be sent is below these limits.
Perishable goods must be sent refrigerated or frozen.
ADDITIONAL INFORMATION
Should you require a certicate for export purposes please ll out a ‘Radioactivity
Certicate Request Form’. Perishable goods will be disposed of 5 days after issue of a
Test Report and all other goods will be disposed of 2 months after issue of a Test Report.
Print out a copy of your completed form and send with your sample to:
Environmental Radioactivity, NCRS, Christchurch Science Centre, 27 Creyke Road, Ilam,
Christchurch 8041
Contact name:
GAMMA ANALYSIS ALPHA SPECTROMETRY
Company:
Cs-137 Am-241 and Pu-239 in milk powder
Goods description:
Street address:
Postal address: Post code
Phone number: Mobile:
Email address:
Cs-134 BETA COUNTING
I-131 Strontium-90
Other (please specify)
Sample quantity:
RESET FORM
ESR USE ONLY
Date received:
Test report no:
AOAD:
Sample number:
Other comments:
ESR0625
vers 4.0 SEPT 2018
INSTITUTE OF ENVIRONMENTAL SCIENCE AND RESEARCH LIMITED
NATIONAL CENTRE FOR RADIATION SCIENCE, Christchurch Science Centre: 27 Creyke Road, Ilam, Christchurch 8041 | PO Box 29181
Christchurch 8540, New Zealand T: +64 3 351 6019 F: +64 3 351 0010
DECLARATION
I agree to pay the charges incurred for this testing.
Name:
Position:
Date: Purchase order number:
INSTRUCTIONS FOR USING FILLABLE FORMS: In Acrobat
Reader DC, please complete this form, then save the pdf
to your
hard drive with a new le name. Email this form to
ncrs.environmental@esr.cri.nz Print out the form, attach to
your product and send to address at base of form.
