SPECIALIZING IN COSMETICS & PHARMACEUTICAL TESTING
Mailing address for submission:
3125 N. Damon Way, Burbank, CA 91505
Phone: (818) 845-0070 • Fax: (818) 845-0030 • E-mail:
MICROBIOLOGY TESTING – SUBMISSION FORM
BUSINESS NAME: / Report No:
PO #:
Date:
BUSINESS ADDRESS: / Street
City State Zip
BILLING ADDRESS
(if different)
Contact Name:
/ Phone: / Fax: / E-Mail: Send Results Via E-Mail
Send Results Via MQL Portal
Special Instructions: / Received /
Integrity Check By:
No. / (Lab Use Only)
Accession #: / Sample Description /
Quantity Provided / Product Code / Batch/Lot / Type of Sample: (FG, Bulk, Raw) / Sample Number (MQL Use Only) / Test Requested / Comments
1.
2.
3.
4.
5.
Results:
No. / TPC/gm.(mL) / Gram. stain / Yeast/Mold
Gm. (mL) / Coliforms / E.coli / Pseudomonas / S.aureus / Salmonella/
Shigella / Enrichment
<10 / Count / +B / +C / GN / <10 / Count / + / - / + / - / + / - / + / - / + / - / Gr+ / NG
1.
2.
3.
4.
5.
Legend:
TPC = Total Plate Count / +B = gram + bacilli / +C = gram + Cocci / GN = Gram negative / Gr. + = Growth / TNTC = Too Numerous to Count
(FOR MQL LAB USE ONLY) CHECK BOX FOR: Nutritional Sample Cosmetic Sample OTC Sample
Chemical SDS included? Yes No Requested Controlled Substance (DEA) DEA License #______
* Note: Hemp test samples must not be food, beverages, or consumable products and are required to meet the definition of DEA legal hemp products. Definition Reference: 21 CFR 1308 Exemption from Control of Certain Industrial Products and Materials Derived from the Cannabis Plant.
The aforementioned results on this report are representative of the samples submitted and may not be indicative of the entire manufacture, batch, and/or lot. Applicable current GMP’s shall always be used when sampling. GLP’s shall always be practiced by Micro Quality Labs to ensure the most accurate results.
Customer Signature______Date______Form #3A.1 DCR2017-0051, Rev 4-19-2017 by AO