Request for Sample Pickup/Testing - RICHMOND TESTING LAB, INC.

REQUEST FOR SAMPLE PICKUP

All information must be filled out completely prior to Richmond Testing Lab scheduling sample pickup.

SECTION 1 - PROJECT INFORMATION

Project Address(required)

Project Borough(required)

If not in NYC, please specify city or town(required)

SECTION 2 - SAMPLE/REPORT INFORMATION

Date Samples Made(required)

Sample Types(required)

Mortar

Grout

Concrete

Other

Please select sample types to be picked up

Specify Other(required)

Concrete Sample Size(required)

Concrete PSI(required)

Concrete Yardage(required)

Concrete Supplier(required)

Concrete Mix Type(required)

Pump or Conventional?

Concrete Mix Weight(required)

Lightweight or Normal weight?

Concrete Placement Location(required)

Concrete Sample Break Sequence(required)

(Eg. 2 1-day; 2 7-day; 3 28-day; 2 56-day)

Concrete Sample ID Number(required)

Mortar Sample Size(required)

Specify Mortar Sample Size(required)

Mortar PSI(required)

Mortar Placement Location(required)

Mortar Break Sequence(required)

(Eg. 2 1-day; 2 7-day; 3 28-day; 2 56-day)

Mortar Sample ID Number(required)

Grout Sample Size(required)

Specify Grout Sample Size(required)

Grout PSI(required)

Grout Placement Location(required)

Grout Break Sequence(required)

(Eg. 2 1-day; 2 7-day; 3 28-day; 2 56-day)

Grout Sample ID Number(required)

SECTION 3 - SAMPLE PICKUP INFORMATION

Site Contact for Pickup(required)

Site Contact Phone Number(required)

Onsite Location of Sample(required)

(i.e. 4th floor - column line, loading dock, etc.)

Your email address(required)

Additional Information (if any)

Type the characters(required)

This field should be left blank

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