试验骗号                

施工单位                            工程名称及部位                         

种类及标号                             收样日期：                          

厂    别：                                 代表数量：                     

试验委托人：                               取样编号：                          

结论：                                                                

负责人：           审核：          计算：         试验：             

报告日期：         年       月        日