APPENDIX C. Chain of Custody Forms
|
|
- Lynn Bradley
- 5 years ago
- Views:
Transcription
1 APPENDX C Chain of Custody Forms
2 CHAN OF CUSTODY Servkes AE,rpo OWdL 1317 South 13th Ave. Kelso, WA (360> (800) x07 FAX (360) SR#: PAGE _ OF 000# PROJECT NAME,'r j PROJECTNMBER PROJECT MANAGER COMPANY ADDRESS CTY STATE S P EMALADORESS PHONE# SAMPLERS '. _ AMPLE.D. DATE ME LAB.D. MRX_ 7 O o,o 0". las) O' _ & p, '!q!1 L!,,. k.... _.. _. NVOCE NFORMATON Circle which metals are to be.jzed: REPORT REQUREMENTS P.O#, Routine Report: Method Total Metals: Al As Sb Ba Be B Ca Cd Co Cr Cu Fe Pb Mg Mn Mo Ni K Ag Na Se S r T Sn V Zn Hg Bill To: Blank, Surrogate, as _ Dissoved Metals: Al As Sb Be Be B Ca Cd Co Cr Cu Fe Pb Mg Mn Mo Ni K Ag Na Se Sr T Sn V Zn Hg * NDCATE STATE HYDRO CARBON PROC EDURE: AK CA W NORTHWEST OTHER : ( CRCLE ONE ). Report Dup., MS, MSD as TURNAROUND REQUREMENTS 24 hr. 48 hr. SPECAL NSTRUCTONSCOMMENTS: ll. Data Validation Report 5 Day (includes all raw data) Standard (1015 working days) V. CLP Deliverable Report Provide FAX Results V. EDD Requested Report Date RELNQUSHED BY: RECEVED BY: RELNQUSHED BY: RECEVED BY: Signature Time Sture ateti Tnature DTme Signature DateTime Printed Name Firm Printed Name Firm Printed Name Firm Printed Name Firm RCOC #1 0603
3 CHAN OF CUSTODY Servi( Os A, Ep,r o rrp 1317 South 13th Ave. Kelso, WA (360) (800) x07 FAX (360) PROJECT NAME PRO, ECT NUMBER _ PRO ECT MANAGER S R#: PAGE _ OF 000# t & COMPANY ADDRESS o; * y, C TY STATE ZP EMA LA DRESS Y _ t\e 1G55) & 9o PHONE FAX 0 'w, cc dj o s, c., SAMPLER'S S ONAT RE eqcoo0co _ SAMPLE D. _ DATE TME LAB D. MATRX, i _!Z KS 4 REPORT REQUREMENTS NVOCE NFORMATON Circle which metals are to be ana(d.. Routine Report: Method Bill To: Total Metals: Al As Sb Ba Be B Ca Cd Co Cr Cu Fe Pb Mg Mn Mo Ni K Ag Na Se Sr T Sn V Zn Hg Blank, Surrogate, as _ Dissolved Metsis: Al As Sb Ba Be B Ca Cd Co Cr Cu Fe Pb Mg Mn Mo Ni K Ag Na Se Sr T Sn V Zn Hg * _ NDCATE STATE HYDROCARBON PROCEDURE: AK CA W N O RTHWEST OTHER: ( CRCLE ONE ). Report Dup., MS, MSD as TURNAROUND REQUREMENTS 24 hr. 48 hr. SPECAL NSTRUCTONSCOMMENTS:. Data Validation Report 5 Day (includes all raw data) Standard (1015 working days) V. CLP Deliverable Report Provide FAX Results V. EDD ReqUested eport Date RELNQUSHED BY: RECEVED BY: RELNQUSHED BY: RECEVED BY: gndtlr'e Dteie Deime Sire DaTime Signature Dirne Printed Nam Fern infm' Firrn Printed Name Firm Printed Name Firm ACOC #1 0603
4 CHAN OF CUSTODY $olumbia Analybi a! L Services Anpior (E, 1317 South 13th Ave. Kelso, WA (360) (800) x07 FAX (360) PAGE PROJECT NAME PRO ECTNUMeER PROJECT MANA ER C) COMPANY ADDRESS CTY STATE S P PHONEE SAMPLERS SONATLRE SAMPLE D. DATE TME &'C MAT ADDRESS PAS & Go 0w, :w LAB D. MATRX :: SR#: OF _ 000# # Jo tj, _ REPORT REQUREMENTS NVOCE NFORMATON PO # Circle which metals are to be analyzed:. Routine Report: Method Bill To: Total Metals: Al As Sb Ba Be B Ca Cd Co Cr Cu Fe Pb Mg Mn Mo Ni K Ag Na Se Sr T Sn V Zn Hg Blank, Surrogate, as _ Dissolved Metals: Al As Sb Ba Be B Ca Cd Co Cr Cu Fe Pb Mg Mn Mo Ni K A g Na Se Sr T Sn V Zn H g *NDCATE STATE HYDROCARBON PROCEDURE: AK CA W NORTHWEST OTHER: (CRCLE ONE). Report Dup., MS, MSD as TURNAROUND REQUREMENTS SPECAL NSTRUCTONSCOMMENTS: 24 hr. 48 hr.. Data Validation Report 5 Day (includes all raw data) Standard (1015 working days) V. CLP Deliverable Report Provide FAX Results V.EDD Requested Report Date RELNQUSHED BY: RECEVED BY: RELNQUSHED BY: RECEVED BY: S gnaturc DateD me nature Dateie nature ime Signature Dateime Pruitod Name Firm Printed Name Firm )nted Name 1T PrinffName Firm RCOC #
5 ,4ji' a Sample Transportation Notice Relinquishing signature on this document indicates that sample is being shipped in compliance with 180 BLUE RAVNE ROAD, SUTE B all applicable local, State, Federal, national, and international laws, regulations and ordinances of FOLSOM, CA L7DC any kind. Air Toxics Limited assumes no liability with respect to the collection, handling or shipping '916) FAX (916) of these samples. Relinquishing signature also indicates agreement to hold harmless, defend, CHANOFCUSTODY RECORD and indemnify Air Toxics Limited against any claim, demand, or action, of any kind, related to the Page of collection, handling, or shipping of samples. DOT. Hotline (800) Project Manager Project nfo: Turn Around Time: 7 Collected by: (Pdnt and Sign) 1 P.O. # J Normal Company Project# JRush V_i Address City State Zip Phone. Fax _..._ Project Name _ specify Date Time Canister PressLre"cuum Lab LU Field Sample LD. (Location) Can # of Collection of Collection Analyses Requested nitial Fin _ Rl nquk ied by: a gnature) DateTime Received by: (signature) DateTime Notes: Relinquished by: (signature) DateTime Received by: (signature) DateTime Relinquished by: (signature) DateTime Received by: (signature) DateTime Lab Name Ar Bil Temp C Condition Custody bedis l!tc'l Yes No None i._ H orm 11
6 g Air TOKCS L1D CHANOFCUSTODy RECORD Sample Transportation Notice Relinquishingsignatureonthisdocumenfindicatesthatsampleisbeingshippedincompliancewith 180 BLUE RAVNE ROAD, SUTE B all applicable local, State, Federal, national, and international laws, regulations and ordinances of FOLSOM, CA any kind. Air Toxics Limited assumes no liability with respect to the collection, handling or shipping of these samples. Relinquishing signature also indicates agreement to hold harmless, defend, ' 916' FAX '( and indemnify Air Toxics Limited against any claim, demand, or action, of any kind, related to the collection, handling, or shipping of samples. DOT. Hotline (800) age Project Manager.. Project nfo Turn Around Time: Collected by: (Printandsn 1 P.O. #_ Normal Company Address Project# _ Rush _City State Zip 4 Phone Fax _ Pioject Name _ sr ify Date Time Canister PressureVanuom i o Field Sample D (Location) Can # of Collection of Collection Analyses Requested nitial Final Piss.: Re nquished by: (signature) DateTime Received by: (signature) DateTime otes: Felinquished by: (signature) DateTime Received by: (signature) DateTime Relinquished by: (signature) DateTime Received by: (signature) DateTime Lab Shipper Name Air Bill i Temp ( C) Condition Custody Seals ntact? Su Srcl:. Yes No None Form 1293 revil
7
ISO INTERNATIONAL STANDARD. Water quality Digestion for the determination of selected elements in water Part 2: Nitric acid digestion
INTERNATIONAL STANDARD ISO 15587-2 First edition 2002-03-01 Water quality Digestion for the determination of selected elements in water Part 2: Nitric acid digestion Qualité de l'eau Digestion pour la
More informationENDF/B-VII.1 versus ENDFB/-VII.0: What s Different?
LLNL-TR-548633 ENDF/B-VII.1 versus ENDFB/-VII.0: What s Different? by Dermott E. Cullen Lawrence Livermore National Laboratory P.O. Box 808/L-198 Livermore, CA 94550 March 17, 2012 Approved for public
More informationActivity concentration for exempt material (Bq/g)
173.436 Exempt material activity concentrations and exempt consignment activity limits for radionuclides. The Table of Exempt material activity concentrations and exempt consignment activity limits for
More informationRow 1 This is data This is data
mpdf TABLES CSS Styles The CSS properties for tables and cells is increased over that in html2fpdf. It includes recognition of THEAD, TFOOT and TH. See below for other facilities such as autosizing, and
More informationRow 1 This is data This is data. This is data out of p This is bold data p This is bold data out of p This is normal data after br H3 in a table
mpdf TABLES CSS Styles The CSS properties for tables and cells is increased over that in html2fpdf. It includes recognition of THEAD, TFOOT and TH. See below for other facilities such as autosizing, and
More informationSupporting Information. Highly Selective and Reversible Chemosensor for Pd 2+ Detected by Fluorescence, Colorimetry and Test Paper.
Supporting Information Highly Selective and Reversible Chemosensor for Pd 2+ Detected by Fluorescence, Colorimetry and Test Paper Mian Wang, Xiaomei Liu, Huizhe Lu, Hongmei Wang* and Zhaohai Qin* Department
More informationQuality of Semiconductor Raw Materials: Evolution and Challenges. Yongqiang Lu Kevin McLaughlin
Quality of Semiconductor Raw Materials: Evolution and Challenges Yongqiang Lu Kevin McLaughlin Outline Advance of Fab technologies and the evolution of raw materials for ever higher quality Challenges:
More informationICP-OES. By: Dr. Sarhan A. Salman
ICP-OES By: Dr. Sarhan A. Salman AGENDA -- ICP-OES Overview - Module removal Optical components and gas control overview Module replacement --Continue module replacement Manual optical alignment --Precise
More informationEnviroChain Laboratory User Guide
EnviroChain Laboratory User Guide EnviroChain Lab Guide Lab Dashboard Table of Contents Introduction... 4 Creating an Account for EnviroChain... 4 Login... 4 Lab Dashboard... 5 Contact Requests... 6 My
More informationTEST REPORT : SCENTCO LIMITED. : China : USA, EU, ASIA. : 16-May EN71 Part 3:2013 Migration of Certain Elements Pass
TEST REPORT Page : 1 of 10 APPLICANT ADDRESS : SCENTCO LIMITED : RM 401, 4/F, SUNG KEE IND. BLDH., 18 KWAI TING ROAD, KWAI CHUNG, N.T., HONG KONG SAMPLE DESCRIPTION VENDOR COUNTRY OF ORIGIN COUNTRY OF
More informationXRF for Regulatory Programs RoHS and Consumer Safety Compliance
Compact X-ray Fluorescence Xpert XRF for Regulatory Programs RoHS and Consumer Safety Compliance RoHS CPSIA EN71-3 Proposition 65 The Xpert for Regulatory Programs Consumer Safety and RoHS Compliance The
More informationPRELIMINARY LABORATORY RADIUM RESULTS FOR POTABLE WATER SAMPLES COLLECTED AUGUST, SEPTMEBER AND NOVEMBER 2012 NWIRP BETHPAGE NY 12/13/2012 H2M LABS
N90845.AR.002015 NWIRP BETHPAGE 5090.3a PRELIMINARY LABORATORY RADIUM RESULTS FOR POTABLE WATER SAMPLES COLLECTED AUGUST, SEPTMEBER AND NOVEMBER 2012 NWIRP BETHPAGE NY 12/13/2012 H2M LABS Bethpage Water
More informationEnviroChain User Guide
EnviroChain User Guide EnviroChain Sample Generator Guide Getting Started Getting Started Login When you are ready to log in, click the Login link in the upper right corner after activating your account
More informationNOTES on: An NJOY Processing Caution when Doppler Broadening
NOTES on: An NJOY Processing Caution when Doppler Broadening 1. Some references about Doppler Broadening CIELO processing Example of files in JEFF-3.2 Example of files in JENDL4.u 2. NJOY versions Official
More informationVI... VIII
- 23 2017 2017 ... VI... VIII... 1 1... 2... 2 1.1... 2 1.1.1... 2 1.1.2... 9 1.1.3... 13 1.1.4... 25 1.1.5... 29 1.1.6... 34 1.1.7... 37 1.1.8... 42 1.2... 47 1.2.1... 47 1.2.2 -... 49 1.2.3... 50 1.2.4
More informationDEFINITIVE ANNUAL REPORT Trace elements 2014
EXPERTISE, SERVICE PROVISION AND CUSTOMER RELATIONS QUALITY OF MEDICAL LABORATORIES CLINICAL BIOLOGY COMMISSION COMMITTEE OF EXPERTS EXTERNAL QUALITY ASSESSMENT IN CLINICAL BIOLOGY DEFINITIVE ANNUAL REPORT
More informationWaleed Pervaiz CSE 352
Waleed Pervaiz CSE 352 Classification Tool: WEKA Waikato Environment for Knowledge Analysis by The University of Waikato. Available on the internet at: http://www.cs.waikato.ac.nz/~ml/weka/index.html The
More informationGEOPT19 - AN INTERNATIONAL PROFICIENCY TEST FOR ANALYTICAL GEOCHEMISTRY LABORATORIES REPORT ON ROUND 19 / July 2006 (Gabbro, MGR-N)
GEOPT19 - AN INTERNATIONAL PROFICIENCY TEST FOR ANALYTICAL GEOCHEMISTRY LABORATORIES REPORT ON ROUND 19 / July 2006 (Gabbro, MGR-N) Peter C. Webb 1 *, Michael Thompson 2, Philip J. Potts 1 and B. Batjargal
More informationTEST REPORT. The following test item(s) was/were performed on submitted sample(s) and/or component(s) confirmed by applicant.
APPLICANT : ADDRESS : TEST REPORT SAMPLE DESCRIPTION : + Hand, Highlighter ITEM NO. : LT81485 COUNTRY OF ORIGIN : China COUNTRY TO IMPORT : The Netherlands AGE REQUESTED ON APPLICATION FORM : >3 LABELED
More information879 - Price Information
879 - Price Information Author: DOT FOODS, INC. Publication: September 24, 2008 879 Price Information Functional Group=QG Purpose: This Draft Standard for Trial Use contains the format and establishes
More informationMEDICAID MARYLAND PART A (MCDMD) PRE-ENROLLMENT INSTRUCTIONS
MEDICAID MARYLAND PART A (MCDMD) PRE-ENROLLMENT INSTRUCTIONS WHAT FORM(S) SHOULD I DO? Maryland Medical Care Programs Submitter Identification Form Trading Partner Agreement o Both Forms must have original
More informationTelecommunications and Internet Access By Schools & School Districts
Universal Service Funding for Schools and Libraries FY2014 E-rate Funding Requests Telecommunications and Internet Access By Schools & School Districts Submitted to the Federal Communications Commission,
More informationThermo Scientific Niton XL2 GOLDD Series Environmental Analyzers Elemental Limits of Detection in SiO 2
Thermo Scientific Niton XL2 GOLDD Series Environmental Analyzers Elemental Limits of Detection in SiO 2 and SRM Matrices Using Soil Analysis In addition to the offices listed below, Thermo Scientific Niton
More informationBOWSER-MORNER, INC. PROCEDURE FOR A NRSB PROFICIENCY TEST
BOWSER-MORNER, INC. PROCEDURE FOR A NRSB PROFICIENCY TEST The following procedure should be used by participants in a Proficiency Test to satisfy the requirements of the National Radon Safety Board s (NRSB
More informationIPR Äspö Hard Rock Laboratory. International Progress Report. TRUE Block Scale project. Summary of chemical data December 2002
International Progress Report IPR-03-25 Äspö Hard Rock Laboratory TRUE Block Scale project Summary of chemical data December 2002 Jeanette Carmström SKB April 2003 Svensk Kärnbränslehantering AB Swedish
More informationCem Kırt.Büro Malz.ve Gıda Tic. Ltd. Şti.
TEST REPORT Page 1 of 16 REPORT NUMBER : APPLICANT NAME ADDRESS SAMPLE DESCRIPTION : BUYER : TURT180108559 Cem Kırt.Büro Malz.ve Gıda Tic. Ltd. Şti. İstoç, 18 Ada Gönül Plaza K:4 Bağcılar - İstanbul FAX
More informationMEMORANDUM SUBJECT: LICENSING AND REGISTRATION OF FERTILIZERS FOR 2007
MEMORANDUM TO: FROM: DISTRIBUTORS AND POTENTIAL DISTRIBUTORS OF FERTILIZER IN KENTUCKY D. L. TERRY, COORDINATOR FERTILIZER REGULATORY PROGRAM DATE: March 14, 2007 SUBJECT: LICENSING AND REGISTRATION OF
More informationTEST REPORT : SCENTCO LIMITED. : China : USA, EU, ASIA. : Not Present. : 16-May : 19-Jun-2014
TEST REPORT Page : 1 of 14 APPLICANT ADDRESS : SCENTCO LIMITED : RM 401, 4/F, SUNG KEE IND. BLDG., 18 KWAI TING ROAD, KWAI CHUNG, N.T., HONG KONG SAMPLE DESCRIPTION VENDOR COUNTRY OF ORIGIN COUNTRY OF
More informationGeoPT22 - MBL-1, Basalt
GeoPT22 - MBL-1, Basalt Veranstalter: International Association of Geoanalysts and Geostandards Newsletter - GeoPT22 Ringversuchsmaterial: MBL-1, Basalt RV geschlossen: 2008 2 Literatur: Proficiency Testing
More informationOn All Forms. Financing Statement (Form UCC1) Statutory, MARS or Other Regulatory Authority to Deviate
Field Action Article 9 Section Jurisdiction Deviations On All Forms Boxes A-C: Contact Information Statutory, MARS or Other Regulatory Authority to Deviate a. The filer fails to provide information in
More informationYOUR BEST ADDRESS 401 E 8 TH ST, STE 214 SIOUX FALLS, SD
YOUR BEST ADDRESS 401 E 8 TH ST, STE 214 SIOUX FALLS, SD 57103 800-419-1690 PAGE 1 Name: APPLICATION FOR TRADITIONAL MAIL FORWARDING SERVICE Name of additional applicant or business: Current address: City:
More informationBlue Sombrero Player Registration AYSO
Blue Sombrero Player Registration AYSO Go to the Region website: New user to Blue Sombrero: Click on Register Now Already a Blue Sombrero user: Click on Log In First Name: Primary Parent Last Name: Primary
More informationNew Generation Explorer Handheld XRF. EXPLORER 7000 Mineral Ore Analyzer
New Generation Explorer Handheld XRF EXPLORER 7000 Mineral Ore Analyzer EXPLORER 7000 Mineral Ore XRF Based on ten-year research and development experience in Handheld X-Ray Fluorescense, Skyray Instruments
More informationSo il Geochem ica l Ba seline and Env ironm en ta l Background Va lues of Agr icultura l Reg ion s in Zhejiang Prov ince.
2007, 23 (2) : 81-88 Journal of Ecology and Rural Environm ent 1, 1, 2, 1 (1., 311203;, 065000) 2. :,, 13,,, 52(), : ; ; ; : P632; X8; P59 : A: 1673-4831 (2007) 02-0081 - 08 So il Geochem ica l Ba seline
More informationMEDICAID MARYLAND PRE-ENROLLMENT INSTRUCTIONS MCDMD
MEDICAID MARYLAND PRE-ENROLLMENT INSTRUCTIONS MCDMD HOW LONG DOES PRE-ENROLLMENT TAKE? Standard processing time is 2 weeks. WHAT FORM(S) SHOULD I COMPLETE? Maryland Medical Care Programs Submitter Identification
More informationVendor Agreement Non-For Profit
Indiana Motorcycle Preservation Society 11071 South E00W Fairmount, Indiana 46928 765-661-8755 www.hogdaze.com Vendor Agreement Non-For Profit This Agreement made and entered into this day of, 2018 by
More informationMATS Transition PDF Reporting Instructions
REPORTING PROCESS Only Designated Representatives (DRs), Alternate Designated Representatives (ADRs), and their agents who have Submit Agent status in the CAMD Business System (CBS) will be able to submit
More information850 Purchase Order. Version: X12
850 Purchase Order Version: 004010 X12 Company: DOT FOODS, INC. Publication: 5/18/2012 850 Purchase Order Functional Group= PO Purpose: This Draft Standard for Trial Use contains the format and establishes
More informationVALUE OPTIONS PRE ENROLLMENT INSTRUCTIONS VALOP
VALUE OPTIONS PRE ENROLLMENT INSTRUCTIONS VALOP HOW LONG DOES PRE ENROLLMENT TAKE? Standard processing time is 1 week. WHAT FORMS DO I NEED TO COMPLETE? You must complete the 2 forms listed below: o Online
More information1. Type of Deposit and Information: Please select the appropriate type of deposit and provide the requested information:
Non-Budapest Treaty Deposit Form (34) Patent Depository 10801 University Boulevard Manassas, Virginia 20110-2209 USA Telephone: (800) 638-6597 Facsimile: (703) 334-2932 Email: patentdeposit@atcc.org THIS
More informationMEDICAID MARYLAND PRE ENROLLMENT INSTRUCTIONS MCDMD
MEDICAID MARYLAND PRE ENROLLMENT INSTRUCTIONS MCDMD HOW LONG DOES PRE ENROLLMENT TAKE? Standard processing time is 2 weeks. WHAT FORM(S) SHOULD I COMPLETE? Maryland Medical Care Programs Submitter Identification
More informationAMERIHEALTH CARITAS DC (77002) ERA ENROLLMENT INSTRUCTIONS
AMERIHEALTH CARITAS DC (77002) ERA ENROLLMENT INSTRUCTIONS WHAT FORM(S) SHOULD I DO? Emdeon ERA Provider Information Form Emdeon ERA Provider Setup Form Optum ERA Setup Form WHERE SHOULD I SEND THE FORM(S)?
More informationBLUE CROSS BLUE SHIELD OF NORTH WEST NEW YORK PRE ENROLLMENT INSTRUCTIONS 00801
BLUE CROSS BLUE SHIELD OF NORTH WEST NEW YORK PRE ENROLLMENT INSTRUCTIONS 00801 HOW LONG DOES PRE ENROLLMENT TAKE? 3 to 5 business days WHERE SHOULD I SEND THE FORMS? Fax the form to 785 290 0720 WHAT
More information867 Product Transfer and Resale Report Functional Group=PT
867 Product Transfer and Resale Report Functional Group=PT This Draft Standard for Trial Use contains the format and establishes the data contents of the Product Transfer and Resale Report Transaction
More informationUsing the Bruker Tracer III-SD Handheld X-Ray Fluorescence Spectrometer using PC Software for Data Collection
Using the Bruker Tracer III-SD Handheld X-Ray Fluorescence Spectrometer using PC Software for Data Collection Scott A Speakman, Ph.D Center for Materials Science and Engineering at MIT For assistance in
More informationANSI X (Advance Shipment Notification) Inbound (to Eclipse) Version 4010
ANSI X12 856 (Advance Shipment Notification) Inbound (to Eclipse) Version 4010 Eclipse 856 4010 (Vendor) 1 10/12/2012 856 Ship Notice/Manifest Functional Group=SH Purpose: This Draft Standard for Trial
More informationElectronic Remittance Advice (ERA) EDI Agreement
Electronic Remittance Advice (ERA) EDI Agreement (Form EDI-801) All New Jersey Medicaid and Charity Care Providers desiring to receive a HIPAA formatted electronic remittance advice (ERA) must complete
More informationINVITATION TO BID. (This is not an order.)
Page 1 of 7 SCHEDULE OF EVENTS Event Description 1 / 1 Motorola Wireless Handheld Programmable Scanner 3.00000 / Motorola Wireless Handheld Programmable Scanner with Touch Panel LED Display Event Date
More informationStep 1. Step 2. Step 3 Choose a Mailbox Service Pricing Term (Check one gray box for your agreement sign up term)
The UPS Store 5883 1657 E Stone Dr Ste B Kingsport, TN 37660 Phone: 423-765-2679 Fax: 423-765-1409 Email: store5883@theupsstore.com Web: www.theupsstore.com/5883 Facebook: www.facebook.com/theupsstore5883
More informationIf you have any questions, please contact the Enrollment Department at , Option 1.
1755 Telstar Drive, Ste 400 Colorado Springs, CO 80920 www.optum.com Value Options Multiple user ids Thank you for choosing Electronic Network Systems Clearinghouse, a division of Optum, to submit your
More informationOshkosh 860 Purchase Order Change Request - Buyer Initiated
Oshkosh 860 Purchase Order Change Request - Buyer Initiated AIAG X12/V4010/860: 860 Purchase Order Change Request - Buyer Initiated Version: 1.0 Final Company: Oshkosh Corporation Publication: 11/13/2015
More informationFigure 1 Map of US Coast Guard Districts... 2 Figure 2 CGD Zip File Size... 3 Figure 3 NOAA Zip File Size By State...
Table of Contents NOAA RNC Charts (By Coast Guard District, NOAA Regions & States) Overview... 1 NOAA RNC Chart File Locations... 2 NOAA RNC by Coast Guard Districts(CGD)... 2 NOAA RNC By States... 3 NOAA
More informationInstitutional Investors Web Registration and Change Form
Institutional Investors Web Registration and Change Form Use this form to authorize, change, or remove online user access to your entity s account on vanguard.com. This form must be signed by the authorized
More informationThe UPS Store XXXX Mailbox Application Kit
The UPS Store 0053 Street Address: 19785 W 12 Mile Rd. Southfield, MI 48076 Phone: 248-559-1690 Fax: 248-559-5884 Email: store0053@theupsstore.com The UPS Store XXXX Mailbox Application Kit Thank you for
More informationDEPARTMENT OF HOUSING AND URBAN DEVELOPMENT. [Docket No. FR-6090-N-01]
Billing Code 4210-67 This document is scheduled to be published in the Federal Register on 04/05/2018 and available online at https://federalregister.gov/d/2018-06984, and on FDsys.gov DEPARTMENT OF HOUSING
More informationCOMMUNICATION ID S. Strouds Voice (626) South Nogales St. City of Industry, Ca Fax (626)
COMMUNICATION ID S Communication Information Strouds Voice (626) 912 2866 780 South Nogales St. City of Industry, Ca 91748 Fax (626) 913 4841 ISA Header Interchange ID Qualifier (ISA 05/07) 01 Interchange
More informationESIS. EDI Implementation Guide. Purchase Order Change X Version 4010 Release 8.0. EDI_Guide_Change_Order_X12_860_Version_4010_Release_8-0.
EDI Implementation Guide ESIS Purchase Order Change X12 860 Version 4010 Release 8.0 Page 1 of 37 EDI Implementation Support Information EDI Contact Name: ESIS, E-Commerce Provider of Raytheon EDI Contact
More informationa ae (Chemi m cal bon o d)
a ae (Chemical bond) å å å a a ooo i o i a ao e e e a ao a a å å å å o æ e и å o e u и 2 ae o æ e и å o e u ( a å o u å o ooo ) æ a ao a a ao e e a a ooo i æ e и a å o e u æ a a o e æ a å a æ o o å å å
More informationHIPAA 837 Claims EDI Agreement. Agreement. HIPAA 837 Claims EDI Agreement
HIPAA 837 Claims EDI Agreement Agreement All New Jersey Medicaid and Charity Care Providers desiring to submit HIPAA formatted electronic claims must complete a HIPAA 837 Claims EDI Agreement as required
More informationSUBJECT: CHAMPION AEROSPACE SLICK SERVICE BULLETIN SB1-12
CONTINENTAL MOTORS, INC AIRCRAFT ENGINE SERVICE BULLETIN Compliance Will Enhance Safety SUBJECT: CHAMPION AEROSPACE SLICK SERVICE BULLETIN COMPLIANCE: As outlined in Slick compliance section Category 3
More informationTEST REPORT MATERIAL SUBMITTED IMPORTER COMPANY MODEL NO SUPPLIER REFERENCE BUYER : : : :
TEST REPORT AB-0505-T MATERIAL SUBMITTED IMPORTER COMPANY MODEL NO SUPPLIER REFERENCE BUYER LAB LOCATIONTURKEY LAB NO. (7217)265-0049 SERVICE TYPE Regular DATE IN September 22 th, 2017 DATE OUT October
More informationStatistics Report,
THE RADICATI GROUP, INC. A TECHNOLOGY MARKET RESEARCH FIRM Email Statistics Report, 2011-2015 http://www.radicati.com Cost US $3,000 by P.O. or $2,500 by credit card A new study from the Radicati Group,
More informationDistracted Driving- A Review of Relevant Research and Latest Findings
Distracted Driving- A Review of Relevant Research and Latest Findings National Conference of State Legislatures Louisville, KY July 27, 2010 Stephen Oesch The sad fact is that in the coming weeks in particular,
More informationELECTRONIC FUNDS TRANSFER (EFT) For Provider Payments
ELECTRONIC FUNDS TRANSFER (EFT) For Provider Payments Alameda Alliance for Health is pleased to announce the availability of Electronic Funds Transfer (EFT). Providers who enroll in EFT will have Fee-For-Service
More informationHEALTHCOMP (85729) ERA ENROLLMENT INSTRUCTIONS
HEALTHCOMP (85729) ERA ENROLLMENT INSTRUCTIONS WHAT FORM(S) SHOULD I DO? Electronic Remittance Advice (ERA) Authorization Agreement Electronic Funds Transfer (EFT) Authorization Agreement WHERE SHOULD
More informationJurisdictional Guidelines for Accepting a UCC Record Presented for Filing 2010 Amendments & the 2011 IACA Forms
Jurisdictional Guidelines for ing a UCC Record Presented for Filing 2010 Amendments & the 2011 IACA Forms The following assumptions apply: 1. The problem described is the only issue; all other information
More informationPREMISES POLLUTION LIABILITY
Beacon Hill Associates, Inc PO Box 1532 Charlottesville, VA 22902 Toll Free: 800) 596-2156 Fax: 434) 979-8964 info@b-h-a.com PREMISES POLLUTION LIABILITY APPLICATION PREMISES POLLUTION LIABILITY COVERAGE
More informationCONTACT INFORMATION. NAME: Last First Middle Initial. HOME ADDRESS (Please do not use P.O. boxes or P.O. ZIP codes as destination of correspondence):
CONTACT INFORMATION NAME: Last First Middle Initial Gender: Male Female Date of Birth: HOME ADDRESS (Please do not use P.O. boxes or P.O. ZIP codes as destination of correspondence): Address City State
More information2018 Supply Cheat Sheet MA/PDP/MAPD
2018 Supply Cheat Sheet MA/PDP/MAPD Please Note: All agents must be contracted, appointed and certified to order supplies and write business. AETNA/COVENTRY Website: www.aetnamedicare.com A. Click For
More informationChange Healthcare CLAIMS Provider Information Form *This form is to ensure accuracy in updating the appropriate account
PAYER ID: SUBMITTER ID: 1 Provider Organization Practice/ Facility Name Change Healthcare CLAIMS Provider Information Form *This form is to ensure accuracy in updating the appropriate account Provider
More informationWELCOME TO OFFICE ALLY!
WELCOME TO OFFICE ALLY! BCBS KANSAS / BCBS KANSAS CITY / MEDICARE OF KANSAS CITY PRE-ENROLLMENT INSTRUCTIONS HOW LONG DOES PRE-ENROLLMENT TAKE? O 3-5 business days WHAT PROVIDER NUMBER DO I USE? O Provider
More informationElectronic Transaction Registration Packet
Electronic Transaction Registration Packet Wellmark Blue Cross and Blue Shield of Iowa and Wellmark Blue Cross and Blue Shield of South Dakota are Independent Licensees of the Blue Cross and Blue Shield
More informationThe UPS Store 4978 Mailbox Application Kit
The UPS Store 4978 519 Somerville Ave Somerville, MA 02143 Phone: 617.591.0199 Fax: 617.591.0299 Email: store4978@theupsstore.com The UPS Store 4978 Mailbox Application Kit Thank you for your interest
More informationSTATE OF FLORIDA FLORIDA DEPARTMENT OF AGRICULTURE & CONSUMER SERVICES FLORIDA GUIDELINES TO SUBMIT THE STATISTICAL REPORT OF FERTILIZER TONNAGE
STATE OF FLORIDA FLORIDA DEPARTMENT OF AGRICULTURE & CONSUMER SERVICES FLORIDA GUIDELINES TO SUBMIT THE STATISTICAL REPORT OF FERTILIZER TONNAGE Bureau of Licensing and Enforcement Fertilizer Section Tel:
More informationELECTRONIC DATA INTERCHANGE. Implementation Guidelines Outbound Purchase Order
ELECTRONIC DATA INTERCHANGE Implementation Guidelines 850 -- Outbound Purchase Order January 2003 Trading Partner EDI Implementation Guide General Overview Electronic Interchange (EDI) is the computer-to-computer
More informationPLEASE DATE ALL PAPERWORK THE DATE OF YOUR 1 ST NEW HIRE ORIENTATION
PLEASE DATE ALL PAPERWORK THE DATE OF YOUR 1 ST NEW HIRE ORIENTATION All paperwork must be printed and completed in blue or black ink only. Follow the instructions for all new hire paperwork and please
More informationANSI X (Purchase Order) Inbound (to Eclipse) Version 4010
ANSI X12 850 (Purchase Order) Inbound (to Eclipse) Version 4010 Eclipse 850 4010 (Customer) 1 10/11/2012 850 Purchase Order Functional Group=PO Purpose: This Draft Standard for Trial Use contains the format
More information3 Months 6 Months 12 Months. Step 1 Choose a mailbox size. Check the box by the box size you would like to sign up for.
The UPS Store 3155 Street Address: 936 SW 1 st Ave, Miami, fl 33130 Phone: 305.858.1221 Fax: 305.858.5548 Email: store3155@theupsstore.com The UPS Store Mailbox Application Kit Thanks for your interest
More informationACTIVANT PROPHET 21 PERSONAL DIGITAL ASSISTANT GUIDE
ACTIVANT PROPHET 21 PERSONAL DIGITAL ASSISTANT GUIDE This manual contains reference information about software products from Activant Solutions Inc. The software described in this manual and the manual
More information867 Bill Back itradenetwork OMS
867 Bill Back itradenetwork OMS X12/V4010/867: 867 Product Transfer and Resale Report Version: 1.3 Final Company: itradenetwork Publication: 12/23/2013 Trading Partner: Current: 4/3/2015 Table of Contents
More informationTEST REPORT GUANGMANG TOY FACTORY GUANGMANG TOY FACTORY
No.202, Building A, Jingye Sanjie, Yushu Industrial Park, Guangzhou Economic & Technology Development Zone, Guangzhou, Guangdong, China Telephone :+86 (0) 20 82019555 Fax :+86 (0) 20 82019556 Email :marketing@stu-lab.com
More information940 Warehouse Shipping Order
940 Warehouse Shipping Order X12/V4030/940: 940 Warehouse Shipping Order Version: 1.0 Author: Abbott Nutrition ebusiness Company: Abbott Nutrition Created: 03/21/2012 Current: 03/21/2012 Table of Contents
More informationThe UPS Store 4978 Mailbox Application Kit
The UPS Store 4978 519 Somerville Avenue Somerville, MA 02143 Phone: 617.591.0199 Fax: 617.591.0299 Email: store4978@theupsstore.com The UPS Store 4978 Mailbox Application Kit Thank you for your interest
More informationPolycom Upgrade Program Video Products
Overview Upgrade Your Existing Polycom Equipment Benefit by owning the latest and greatest additions of the Polycom Office, a complete conferencing solution, by upgrading your Polycom video conferencing
More informationPage 1 of 21. Friday, June 30, Mr. Eric Cureton THE EI GROUP, INC. 15 E SALEM AVENUE, SE SUITE 301 ROANOKE, VA TEL: FAX: (540)
REI Consultants, Inc. PO Box 286 Beaver, WV 25813 TEL: (304) 255-2500 Website: www.reiclabs.com 3029-C Peters Creek Road Roanoke, VA 24019 TEL: 540.777.1276 1557 Commerce Road, Suite 201 Verona, VA 24482
More informationRevised Dear Board of Zoning Appeals Applicant:
Revised 2018 Dear Board of Zoning Appeals Applicant: As part of your application process, you are required to notify surrounding property owners of the Board of Zoning Appeals public hearing to consider
More informationAccount Switch Checklist
Account Switch Checklist You may check the boxes next to the items you ve completed (if any), then print out and keep this checklist handy. As you continue completing items, simply check off the boxes
More informationThe Recovery and Monitoring Program of New Jersey (Keep this sheet for your files)
Welsh Commons, 1364 Welsh Road, Suite C-2, North Wales, PA 19454-1913, USA 800-732-DRUG (3784) Fax: 215371-1126 Internet: http://www.firstlab.com E-mail: mail@firstlab.com The Recovery and Monitoring Program
More informationANSI X (Purchase Order Acknowledgment) Inbound (to Eclipse) Version 4010
ANSI X12 855 (Purchase Order Acknowledgment) Inbound (to Eclipse) Version 4010 Eclipse 855 4010 (Vendor) 1 10/12/2012 855 Purchase Order Acknowledgment Functional Group=PR Purpose: This Draft Standard
More informationTEST REPORT PRODUCT UPGRADING AND RECYCLING
TEST REPORT PRODUCT UPGRADING AND RECYCLING Report No. Approved by (Signature) : 15-07-QAR-002 : Date of issue : 2015/ 07/ 22 Contents : 25 Pages Testing Laboratory Name : Electronics Testing Center, Taiwan.
More informationValue Options. Submit the completed Payer Request Form to: INSTRUCTIONS
Value Options Submit the completed Payer Request Form to: ABILITY Network, ATTN: Enrollment EMAIL: setup@abilitynetwork.com INSTRUCTIONS Complete all sections of the form if - You are a billing service
More information360 DATA COLLECTION & FEEDBACK REPORTING
ADMINISTRATIVE GUIDE FOR HUMAN RESOURCE CONTACTS 360 DATA COLLECTION & FEEDBACK REPORTING REVISED JANUARY 2003 COPYRIGHT 1994, 2001, PERSONNEL DECISIONS INTERNATIONAL CORPORATION ALL RIGHTS RESERVED PREFACE
More informationFleet Card Set Up. Section I: Reporting Parameters (to be completed by PA or A/OPC) Section II: Applicant Information (to be completed by Applicant)
Note: This form should be completed by the Agency/Organization Program Coordinator with the required information input from the Applicant. Please complete the application by typing in the data and printing
More informationBPN-SAS-F424-A6 Backplane USER'S GUIDE
MH JP 4 4 JP0 C48 C44 C45 J0 J J ACT LED TEST MH C5 C4 C6 J9 J -:RST -:NO RST J8 4 U4 44 SB# SB# MH 6 8 8 5 SUPER DESIGNED IN USA V 5V V 5V #5 #4 JP4 BPN-SAS-F44-A6 BAR CODE REV.0 # # ATMEL RST R45 R0
More informationChange Healthcare CLAIMS Provider Information Form *This form is to ensure accuracy in updating the appropriate account
PAYER ID: SUBMITTER ID: 1 Provider Organization Practice/ Facility Name Change Healthcare CLAIMS Provider Information Form *This form is to ensure accuracy in updating the appropriate account Provider
More informationOctober 9-11, 2012 Lenexa, KS
NEBB s Cleanroom Performance Testing Certified Professional Seminar and Exam October 9-11, 2012 Lenexa, KS Introduction: NEBB, in continuance of its policy to enhance education and training within the
More informationCredit Card Setup Application
Credit Card Setup Application U.S. Accounts Only This document contains the information needed to set up your Merchant Account. For a Merchant Service Provider, we recommend Priority Wash. Please see the
More informationELECTRONIC FUNDS TRANSFER FOR PROVIDER PAYMENTS
ELECTRONIC FUNDS TRANSFER FOR PROVIDER PAYMENTS Gold Coast Health Plan along with our contractor, ACS (a Xerox Company), is pleased to announce the availability of Electronic Funds Transfer (EFT). Providers
More informationTHE UNIVERSITY OF TENNESSEE Purchasing Department 5723 Middlebrook Pike Knoxville, TN 37921
DocuSign Envelope ID: 835F4F2C-A64C-4E4B-AD22-9C9FE6F0409E THE UNIVERSITY OF TENNESSEE Purchasing Department 5723 Middlebrook Pike Knoxville, TN 37921 Page 1 of 2 Ship To: C/O Department All University
More information