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.
99-13
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
_X_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. 3-1. DA Form 1804
Once this information has been transferred to the DA Form 2077, the senior technician then enters the
following information:
Sample No.
Lab Report No.
Type of Test(s) to be Performed According to Specification Requirements.
Date Sample Received.
Date Test Started.
Date Test Completed.
Upon completion of the specified test(s), the laboratory technician forwards the results to the senior
laboratory technician for review. The senior laboratory technician reviews the results for accuracy and enters
the results and a recommendation for disposition on the DA Form 2077 "work copy" and forwards it to the
laboratory NCOIC for review approval.
Once the petroleum laboratory NCOIC has approved the results and disposition recommendation, a
typed DA Form 2077 is prepared from the approved work copy. The original is kept in a permanent file and
enough copies to satisfy all interested parties are forwarded to the requesting agency.
3-4
QM 5181
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