90 BULLETIN 940, U. S. DEPARTMENT OF AGRICULTURE. 



(Name and location of laboratory.) 

 Report on Sample of (Miscellaneous Materials). 



Laboratory No 

 N 



ame 



Identification marks 



Submitted by 



Sampled 



Sampled from 



Quantity represented 



Source of material 



Location used or to be used . 

 Examined for 



192. 



. , 192 . . . Received 



192. 



TEST RESULTS. 



Respectfully submitted, 



(Title.) 



