Fillable Pacic Coast Analytical Services Food Sample Submission Form

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Pacic Coast Analytical Services Food Sample Submission Form

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Food Sample Submission Form
Date: __________________ Sample Name: ___________________________
Test:
Shelf Life Testing
(6 x 100g/4oz)
Complete Step 4
Nutritional Analysis
(100g/4oz)
Complete Step 5
Guaranteed Analysis
(100g/4oz)
Proximate Analysis
(100g/4oz)
Allergen Testing
(50g/2oz)
Food Safety/Environmental Swabbing
(100g/4oz)
Storage Conditions:
Refrigerated Room Temperature Other (Specify)
Ingredients and Recipe (Required for Nutritional Analysis):
Company Name:: __________________ Contact: ___________________________
Email: ___________________________________ Phone: ______________________________
Address: _________________________________________________________________________
The client is responsible for specically listing all laboratory
testing to be performed and for supplying Pacic Coast
Analytical Services, LLC with an accurate list of ingredients
and any other distinguishing elements present that may
aect the testing procedure or outcome. An example of a
distinguishing ingredient is alcohol or marijuana.
Check this box to Conrm Understanding.
Shipping info:
Ship To:
PCAS
1824 1st Street
San Fernando, Ca 91340
Consult Sample Size Requirements on our Resources Page.
Include Step 6 completed forms with your package.
Ship Next Day or 2nd Day Air with cold packs, if necessary.
Ship samples in air tight, shatter-proof, secure containers.
Samples are available for receiving Monday through Friday only.
We provide nutrition information based on US FDA regulations with the accuracy of the label content 100% dependent on what we receive
from you, our client. Laboratory service results are dependent on both the ingredients in your product and the quality of the product sample
you send to us. Product quality is dependent on the product temperature when shipped and the integrity of the sample we receive from you.
We are not responsible for any errors that may occur based on your input or for samples received in poor condition. PCAS is not responsible for
any consequential damages. All claims against PCAS are limited to the cost of services rendered.
Step 1
Step 2
Step 3
Study Duration (Shelf Life ONLY)
Step 4
1 Week (Day 0, 3, 4, 5, 6, 7) 1 Month (Day 0, 7, 14, 20, 25, 30) 3 Month (Day 0, 30, 45, 60, 75, 90)
6 Month (Month 0, 2, 3, 4, 5, 6) 1 Year (Month 0, 3, 6, 8, 10, 12)
2 Year (Month 0, 5, 10, 15, 20, 24)
Other ______________ (Pull Dates _________, _________, _________, _________, _________, _________)
Pacic Coast Analytical Services
1824 1st Street San Fernando CA 91340 Tel. 818.364.7470 Fax 818.364.7472
Step 5
Step 7
Step 6
Sample Submission form.
Chain of Custody (CoC).
Non-Disclosure Agreement.
Print and ll out the following forms:
Credit Card Authorization Form.
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Pacic Coast Analytical Services Food Sample Submission Form

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Completed 9 March 2021

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