PART I - DA FORM 1804 COMPLETION
The following information must be entered on DA Form 1804 (Figure 6-12) for each sample taken and/or
submitted:
Product.
From (Requesting Activity).
Sample No. (Entered by lab).
Laboratory No.
Specification No.
Amt. Product Sample Represents.
From (Where sample was taken from).
Source (What storage type sample was taken from: Truck No., Tank No., Other).
Sampled By (Individual).
Stock Number.
Date Sampled.
Shipment Delivery Date.
Fuel Origination.
Sample Type.
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 6-12. DA Form 1804 (Petroleum Sample).
6-15
QM 5097
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