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)
Figure 1-1, DA Form 1804 (Petroleum Sample).
The proper completion of DA Form 2077 cannot be stressed enough; as you know, there are many factors
involved with the recommended disposition of petroleum products. Some of these factors are as follows:
Large amounts of product.
Mission-essential requirements.
Safety.
Environmental concerns.
As a senior laboratory NCO you must make every effort to ensure that DA Form 2077 is completed as we have
discussed and reviewed for accuracy at the required intervals.
QM 5184
1-4
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