DA FORM 1804
REPLACES EDITION OF
1 DEC 62, WHICH IS
1 NOV 67
OBSOLETE,
PETROLEUM
SAMPLE
USE REVERSE SIDE
(FM 10-67-1)
FOR REMARKS
PRODUCT
COMBAT GRADE TYPE I MOGAS
FROM (Installation)
CHARLIE COMPANY, 103RD QM BATTALION
SAMPLE NO.
LABORATORY NO.
013
PRODUCT
COMBAT GRADE TYPE I MOGAS
SPECIFICATION NO.
AMT. PRODUCT SAMPLE
MIL- G - 3056
REPRESENTS
75,000 GALLONS
FROM (Intallation)
CHARLIE COMPANY, 103RD QM BATTALION
MANUFACTURER / SUPPLIER
FRANKLIN OIL COMPANY, LAFAYETTE, LA
SAMPLE
TRUCK NO.
TANK NO.
OTHER
(Specify)
SOURCE
9
SAMPLED BY (Name)
ARMED SERVICES PROCUREMENT
PVT. W. BANKS
NO.
STOCK NO.
DATE SAMPLED
9130- 00- 160 - 1818
15 JAN 1999
QUALIFICATION NO.
BATCH NO.
NA
NA
FILL DATE
SHIPMENT DELIVERY DATE
NA
27 DEC 1998
CONTRACT BULLETIN NO.
ITEM NO.
NA
NA
___FUEL BULK
___ROUTINE
___FUEL PACKAGED
___PROCUREMENT
STORAGE
SURVEILLANCE
ORIGIN
___ALLIED
___PROCUREMENT
___FILTER
PRODUCTS
EFFECTIVENESS
___SPECIAL
___QUAL
___DEPOT
CONTRACT
TYPE SAMPLE
___TOP
___MIDDLE
_X_BOTTOM
___COMPOSITE
__OTHER (Specify)
Fig. 4-7. DA Form 1804
4-14
QM 5180
Previous Page
