EPA QSPF-050-4 Rev C-CUSTOMER INFORMATION FORM.pdf
PDF 242 KB Posted
- Contract number
- 26-532EPA-LAB53-P-84420
- Issued by
- Illinois
About this file
This document is a Customer Information Form from Gold Standard Diagnostics, dated 7/21/2025, for the IEPA (Illinois Environmental Protection Agency) Laboratory located in Springfield, Illinois. The form captures critical contact, billing, shipping, and tax information for the organization, with Carrie Dirksen listed as the primary contact.
The form provides comprehensive details for IEPA Laboratory, including a billing address at 2520 West Iles Avenue in Springfield, IL, and a shipping address at 825 N. Rutledge, also in Springfield. The document includes the state tax ID number E99887169 and indicates the laboratory's contact information with a phone number of 2175570271 and an email address of carrie.dirksen@illinois.gov. The form is designed to facilitate potential procurement or service arrangements, though specific contract details are not elaborated within this document.
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Text version
QSPF-050-4 Rev C
QA RELEASE
Effective Date: 04/14/2020
CUSTOMER INFORMATION FORM
Please TYPE in all fields and do not abbreviate.
All fields are required, if not complete this could result in delay of order/shipment.
If not applicable, please type N/A
DATE:
Rep. Name:
CONTACT INFORMATION
Contact Name
Company Name
Company Street Address
City State Zip Code
Country Company Phone #
Email Address
ACCOUNT PAYABLE CONTACT
AP Contact Name
AP Phone # AP Email
Billing Address 1 Invoicing Email
Billing Address 2 State
City Zip Code
SHIPPING ADDRESS
Shipping Address 1 City
Shipping Address 2 State
Attn: Zip Code
SHIPPING METHOD (If none checked, default will be pre-pay and add)
☐ PREPAY/ADD ☐ CUSTOMER ACCOUNT: ACCOUNT #
CARRIER NAME:
SALES TAX INFORMATION
If customer is Exempt or Direct Pay Permit a certificate Must be provided
State Tax ID #
Reseller #
620 Cantrill Drive · Davis, CA 95618 · (530) 759-8012 ·Finance@gsdx.us mailto:Finance@gsdx.us
| DATE: 7/21/2025 |
| Rep Name: IEPA Lab |
| Contact Name: Carrie Dirksen |
| Company Name: IEPA Laboratory |
| Company Street Address: 825 N. Rutledge |
| City: Springfield |
| State: IL |
| Zip Code: 62702 |
| Country: USA |
| Company Phone: 2175570271 |
| Email Address: carrie.dirksen@illinois.gov |
| AP Contact Name: Fiscal/Procurement |
| AP Phone: |
| AP Email: epa.fiscalserv@illinois.gov |
| Billing Address 1: 2520 West Iles Avenue |
| Invoicing Email: epa.fiscalserv@illionis.gov |
| Billing Address 2: |
| State_2: IL |
| City_2: Springfield |
| Zip Code_2: 62704 |
| Shipping Address 1: 825 N. Rutledge |
| City_3: Springfield |
| Shipping Address 2: |
| State_3: IL |
| Attn: Carrie Dirksen |
| Zip Code_3: 62702 |
| PREPAYADD: Off |
| SHIPPING METHOD If none checked default will be prepay and add: Off |
| CUSTOMER ACCOUNT ACCOUNT: |
| CARRIER NAME: |
| State Tax ID: E99887169 |
| Reseller: |
File details come from the government source that posted it. Updated .