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O. NUMBER 5. END ITEM AND/OR PROJECT 10 MATERIAL TO BE TESTED 6. SAMPLE NUMBER 10a* QUANTITY SUBMITTED 13. PURCHASED FROM OR SOURCE 7. LOT NO. 8. REASON FOR SUBMITTAL 9. DATE SUBMITTED 11. QUANTITY REPRESENTED 12. SPEC. AMEND AND/OR DRAWING NO. REV. FOR SAMPLE DATE 14. SHIPMENT METHOD 15. DATE SAMPLED AND SUBMITTED BY 16. REMARKS AND/OR SPECIAL INSTRUCTIONS AND/OR WAIVERS* 17. SEND REPORT OF TEST TO SECTION B - RESULTS OF TEST Continue on plain white paper if more space is required 1. PAGE NO. ...

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