SGS-REC-199 v1.0 Food Sampling Request Form - Unlock

FOOD SAMPLING REQUEST FORM
Customer Details Sampling Schedule For SGS Office Use Only

Reporting Company : Sampling Date : Ref. No. :
Address : Sampling Time : Sample ID :
Billing Company (if different from the above) : Sampling Venue : TAT : 5-7 Working Days
Address : Total samples : samples of Food
Contact Person : samples of Swab Payment Term : COD
Tel. : samples of Water 30 Days
Email : samples of Ice
Test report to be sent to Reporting Company Billing Company
Information to be included in the test report as SAMPLE MARKING: (Please check appropriate box(es) and fill in the below if information is needed in the report) ^Types of Sample Packing
FOOD WATER / ICE HAND SWAB SURFACE SWAB
Sample Name Sampling Date Sample Name Staff Name Swab Surface (1) No Packing
Sampling Location Sampling Time Sampling Date Staff ID Department
Production Date / Prepared Date Food Temperature (During Sampling) Sampling Time Department Sampling Date (2) Consumer Pack
Best Before Date / Expiry Date Food Temperature (SGS) Sampling Location Sampling Date Sampling Time (3) Customer Pre-pack
Sample Prepared Time Others (please specify) : Others (please specify) : Sampling Time Others (please specify) :
Receiving Date Others (please specify) : (4) Others (please specify):
All orders are executed in accordance to the General Conditions of Services, copy available upon request. This message is sent in confidence for the addressee only. The contents are not to be disclosed
to anyone other than the addressee. Unauthorized recipients are requested to preserve this confidentiality and to advise the sender immediately of any error in transmission.
Doc. No.: SGS/REC/199, Ver.:1.0, Effective Date: 11/09/2017, Page 1 of 7
FOOD Sample Details

Food Temperature (°C) *Best Before
During SGS # D
*Production Date a
/ t
Sample Condition P e
D r
ur e
p /
in
a E
g
Sampling r x *Sample *Receiving
No. Sample Name Food Category S Remarks
e p
a
d i
m
r
pl
y
in d
g a
t D
e a
t
e
1. ^Packing:
Raw Hot
Ready-To-Eat Ambient
Raw & Ready-To-Eat Chilled
Water Frozen
Ice
2. ^Packing:

Raw Hot
Water Frozen
Ice
3. ^Packing:

Raw Hot
Water Frozen
Ice
* Fill in if applicable. ^ Refer to Types of Sample Packing. # To be filled in by CS (S22) and Lab (Pasir Gudang & Prai)
FOOD Sample Details

Food Temperature (°C) *Best Before
During SGS # D
*Production Date a
/ t
Sample Condition P e
D r
ur e
p /
in
a E
g
Sampling r x *Sample *Receiving
No. Sample Name Food Category S Remarks
e p
a
d i
m
r
pl
y
in d
g a
t D
e a
t
e
4. ^Packing:
Raw Hot
Water Frozen
Ice
5. ^Packing:

Raw Hot
Water Frozen
Ice
6. ^Packing:

Raw Hot
Water Frozen
Ice
7. ^Packing:

Raw Hot
Water Frozen
Ice
8. ^Packing:

Raw Hot
Water Frozen
Ice
* Fill in if applicable.
^ Refer to Types of Sample Packing.
# To be filled in by CS (S22) and Lab (Pasir Gudang & Prai)
HAND SWAB Sample Details SURFACE SWAB Sample Details

*Sampling
L
o
c
No. Staff Name *Staff ID a *Sampling Time Remarks No. Swab Surface *Sampling Location *Sampling Time Remarks
t
i
o
n
1. 1.
2. 2.
3. 3.
4. 4.
5. 5.
* Fill in if applicable.
Test & Methodology – please check ( ) required test parameters and test methods in the respective boxes and define quantity of sample.
Microbiology Test for Raw Food (**Only for product containing nuts)
Test Parameters Test Method Specification Unit Price (MYR) Package Price (MYR) Quantity
Total Plate Count AOAC 966.23 AOAC 986.33, 989.10 & 990.12, 37°C for 48 hours
BS EN ISO 4833-1:2013, 37°C for 48 hours
Enterobacteriaceae BS ISO 21528-1: 2004 BS ISO 21528-2: 2004 AOAC 2003.01
Coliform BS ISO 4831:2006 AOAC 986.33, 989.10 & 991.14 BS ISO 4832:2006
Fecal Coliform In house based on BAM Chapter 4
E. coli BS ISO 7251:2005 AOAC 991.14 & 998.08
In house based on Merck Manual
Staphylococcus aureus BS EN ISO 6881-1: 1999 AOAC 2003.07, 2003.08 & 2003.11
Salmonella in 25g BS EN ISO 6579:2002 AOAC 967.25, 967.26 & 978.24
Vibrio cholerae AOAC 998.20
Vibrio parahaemolyticus AS/NZS 1766.2.9
Listeria In house based on FDA/BAM Chapter 10
In house based on BS EN ISO 11290-1: 1997, BS 5763-18 1997
Listeria monocytogenes In house based on FDA/BAM Chapter 10 BS EN ISO 11290-1: 1997, BS 5763-18 1997
Bacillus cereus In house based on FDA/BAM Chapter 14 ISO 7932: 2004
Clostridium perfringens BS EN ISO 7937:2004 In house based on AOAC 976.30
Campylobacter Subcon
Yeast & Mould AOAC 997.02 ISO 21527
Aflatoxin** ELISA HPLC-FLD
Microbiology Test for Ready-To- Eat Food (**Only for product containing nuts)
E. coli BS ISO 7251:2005 AOAC 991.14 & 998.08
Microbiology Test for Raw & Ready-To-Eat Food (**Only for product containing nuts)
E. coli BS ISO 7251:2005 AOAC 991.14 & 998.08
Testing for Swab
Total Plate Count AS1766.1.3 In house based on BS EN ISO 4833-1:2013, 37°C for 48 hours
Coliform AS1766.2.3 In house based on BS ISO 4832:2006 and Merck Manual
E. coli AS1766.2.3 In house based on BS ISO 4832:2006 and Merck Manual
Staphylococcus aureus In house based on BS EN ISO 6881-1: 1999
Salmonella In house based on BS EN ISO 6579:2002
Listeria In house based on BS EN ISO 11290-1: 1997, BS 5763-18 1997
In house based on FDA/BAM Chapter 10
Yeast & Mould AS1766.2.2 In house based on ISO 21527-1:2008
Testing for Water
Total Plate Count APHA 9215 D, 37°C for 48 hours APHA 9215 D, 22°C for 48 hours
APHA 9215 B
Coliform APHA 9221 B APHA 9222 B
E. coli APHA 9221 F In house SGS-TM-04-018 based on APHA 9222 B
APHA 9222 D
Fecal Coliform APHA 9221 E APHA 9222 D
Fecal Enteroccoccus / Streptococcus Groups In house SGS-TM-04-026 based on APHA 9230 C APHA 9230 B
Pseudomonas aeruginosa APHA 9213 E
Clostridium perfringens ISO 14189: 2013
Legionella ISO 11731:1998-5-01
Sulphite Reducing Anaerobes ISO 6461/2: 1986
Turbidity APHA 2130 B
pH APHA 4500-H+ B
Colour APHA 2120 B
Conductivity APHA 2510 B
Residual Chlorine APHA 4500-Cl B&G
Total Dissolve Solid APHA 2540 C
Iron APHA 3125 B
Copper APHA 3125 B
Aluminium APHA 3125 B
Testing for Ice

Total Plate Count APHA 9215 D, 37°C for 48 hours APHA 9215 D, 22°C for 48 hours
APHA 9215 B
Coliform APHA 9222 B
E. coli APHA 9222 D
Fecal Coliform APHA 9222 D
Fecal Enteroccoccus / Streptococcus Groups In house SGS-TM-04-026 based on APHA 9230 C
Pseudomonas aeruginosa APHA 9213 E
Clostridium perfringens ISO 14189: 2013
Sulphite Reducing Anaerobes ISO 6461/2: 1986
Residual Chlorine APHA 4500-Cl B&G
Other Testing (If not stated above, please specify in below) ***Subcon testing

Optional Charges
Emergency Service (additional 50% Surcharge on actual test fees) : TAT: working days Handling: RM / Trip
Draft report before issuance of E-report : RM30 per sample. Transport: RM / Trip
Issuance of hard copy of report on top of E-report : RM30 per copy
Remark:
 Rate quoted EXCLUDES ANY BANK CHARGES incurred during overseas transmission of payment to SGS Malaysia.
 If testing fees per submission is below RM150, there will be a minimum charge of RM150 for that invoice.
 ***Subcon testing - Dispatch charge will be charged at cost & to be borne by your company.
Total Testing Fee Before GST (RM) :
Payment Details
Bank-in details : SGS (M) Sdn Bhd
Citibank : 0-115001-019
Maybank : 014329-400853
Upon payment made, kindly send payment slip via fax (03-5481 8215) attn: Wendy Teh (wendy.teh@sgs.com) / Xindy Lim (Xindy.Lim@sgs.com)
Remarks
Standard Instruction : Temperature needs to be recorded for all the food samples during collection & upon arrival in the lab.
Remarks :
Special Instruction (if any) :
We confirm acceptance on the above rates, test method and hereby instruct SGS (M) Sdn. Bhd. to proceed with the testing upon receipt of samples.
On-Site Sampling Acknowledgement For SGS Office Use Only
Customer Signatory Sampler Signatory Customer Site Representative Signatory Sample Received By Sample Logger Signatory ∞
Signature : Signature : Signature : Signature : Signature :
Name : Name : Name : Name : Name :

Date : Date : Date : Date : Date :
Company Stamp : Time : Company Stamp : Time : Time :
All samples collected MUST BE RETURNED to SGS office within 4 hours. ∞ To be filled by lab for Prai
and PG
CTS Ref: BOSS :

SGS-REC-199 v1.0 Food Sampling Request Form - Unlock

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FOOD SAMPLING REQUEST FORM

Customer Details Sampling Schedule For SGS Office Use Only

FOOD Sample Details

2. ^Packing:

3. ^Packing:

FOOD Sample Details

5. ^Packing:

6. ^Packing:

7. ^Packing:

8. ^Packing:

HAND SWAB Sample Details SURFACE SWAB Sample Details

2. 2.

3. 3.

4. 4.

5. 5.

Testing for Ice

Name : Name : Name : Name : Name :

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