Shipping Address (if different than purchaser Address):
Street _______________________________
City _______________________________
State _______________________________
Zip _______________________________
Date of Shipment _______________________________
Description of Listed Chemical:
Chemical Name _______________________________
Quantity _______________________________
National Drug Code (NDC) Number(s), or Form(s) of Packaging _______________________________
Other:
The basis (i.e., reason) for making the report: _______________________________
Any additional pertinent information:_______________________________
21 C.F.R. §1310.06