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PDEA Ordering Record - Diazepam (Valium) Amp
PDEA Ordering Record - Diazepam (Valium) Amp
Date Received Supplier Information: Name, Address, PDEA Quantity Date Sold or S4/S3 License Local Permit Quantity Sold Balance
Name of Purchaser Address Name of Trucker/Carrier
License No., Local Permit No., Date Issued Received Delivered No. No. or Delivered