SAURASHTRA ENVIRO PROJECTS PRIVATE LIMITED
                         Corporate Office: Detox House, Opp. Gujarat Samachar Press, Udhna Darwaja, Ring Road, Surat.
                                  Contact Nos. : 0261 – 2351248, 2346181, 6542020;  E-mail: info@sepplindia.com
                                                Sample Submission Form
              Name of the Company
              Address
              (Complete postal address with Pin Code)
                                              Name:
              Contact person details       Designation:
                                           Department:
              Contact Details                               Mobile:                            E-mail Address:
              Please Attach List of Raw materials used in 
              the Process
              Safety Measures for handling waste (use of 
              masks, hand gloves, safety goggles etc)
               Physical State of Waste (“Mark” the relevant)              Type of Waste II (“Mark” the relevant)
                  o Solid              o Liquid                 o ETP Sludge                  o Liquid Waste
                  o Semi-solid         o Slurry                 o Process Residue             o Other_______________
              Details of Waste as per CCA                   Name:                          Category:
              Date & Time of sample collection              Date:                          Time:
              Sample location or sample code                Location:                      Code:
              Quantity of sample required                   Solid sample: 250 Gms (max.)   Liquid sample: 1.0 Litre (max.)
              Mode of submission
              Terms & Conditions:
              Sample Submission Form & Fees shall be different for each sample.
              Sample Submission Form to be submitted along with Sample is a mandatory requirement. Sample submitted with any
              incomplete / misleading information shall not be accepted.
                                                   FOR SEPPL OFFICE USE ONLY
               Date of receipt of Sample                   Sale Order No.
               Sample Received By                          Sample Submitted to Lab on
               F/MKT/15/01                                                                           01.06.2015