Refrigerant Analysis Sheet "*" indicates required fields Type of Test* Liquid Vapor Note: Separate cylinders are required if both tests are necessaryChiller tested by Hudson?* Yes No Analysis part of Chiller Chemistry?* Yes No Analysis part of Fluid Chemistry?* Yes No Hudson SO # Customer Information Company Name* Contact Name* Address* Address Line 2 City* State*Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip Code* Email* Enter Email Confirm Email Phone*Purchase Order # Job Reference Sample Point Information Sample Taken By Refrigerant Charge Refrigerant*SelectR11R12R22R113R114R123R134aR407CR410AR500R502R507OtherOther: Refrigerant Type Sample Source*SelectReceiverEvaporatorCondenserOtherOther: Sample Source Sample Condition* System Operating System Off Refrigerant Temperature at Time of Sampling° FahrenheitChiller Duty*SelectComfort CoolingChemical ProcessOtherOther: Chiller Duty Heat Transfer Fluid*SelectWaterEthylene GlycolCalcium ChlorideOtherOther: Heat Transfer Fluid Equipment Information Chiller Manufacturer* Chiller Model #*TonnageChiller Serial #*Chiller Name / Location Comments Note: Unless you have made other arrangements with your Hudson Technologies Territory Manager; Please send your completed sample cylinder to: Hudson Technologies 3402 North Mattis Avenue Champaign, IL 61821 ATTN: Lab (217) 373-1414