LUBRICANT VISION, INC. — SAMPLE INFORMATION SHEET

Complete one record per sample. This sheet is not a shipping authorization.
Call 281-271-8505 before collecting or shipping material.

CONTACT
Name:
Company:
Email:
Phone:

SAMPLE IDENTIFICATION
Sample ID:
Sampling date and time:
Site:
Asset ID:
Equipment manufacturer / model:
Component / application:
Sampling point:
Operating or shutdown when sampled:
Collection procedure:

LUBRICANT
Manufacturer:
Full product designation:
Viscosity / grease grade:
Lubricant service hours or mileage:
Equipment total hours or mileage:
Operating temperature (if known):
Top-up amount and dates:
Product changes or known mixing:

REASON FOR ANALYSIS
Concern / observed symptoms:
Recent maintenance:
Previous sample IDs or reports:
Available product / OEM reference information:
Requested analytical scope (to be agreed):

PRE-SHIPMENT CHECK
[ ] Scope and methods agreed
[ ] Sample volume and container confirmed
[ ] Acceptance and receiving address confirmed
[ ] Handling / carrier requirements checked
[ ] Safety data sheet provided when requested
[ ] Sample ID matches this record

BUSINESS CONTACT — NOT A STANDING SAMPLE RECEIVING ADDRESS
Lubricant Vision, Inc.
12218-D Jones Rd, Suite 220
Houston, TX 77070
281-271-8505