COMPANY LOGO: IOC BPC HPC

SAMPLE LABEL - SAMPLES DRAWN FROM RETAIL OUTLET

SUPPLY LOCATION: ___________________

DIVISION/TERRITORY/REGIONAL OFFICE: _____________
Name of the Retail Outlet:
Name of the Oil Company:
Product: MS/HSD
Source of sample:
Dispensing Unit No. ___________
Tank No._______________
Samples drawn on _____________ at ___________ hours
Density at 15 Deg C
a) As recorded in the Density register ________
b) Observed by inspecting officer ________

Date of last receipt of product in this tank: ______________

Tank Lorry No. of last receipt _______________

Plastic Seals Nos. of Aluminium container: ________________

Plastic Seals Nos. of wooden box: ________________

Certified that empty containers are rinsed in my presence with the same product before
drawing of samples and that one (1) set of samples out of the 3 sets of samples drawn has
been handed over to me for retention in safe custody till further advice from Oil Company.

Signature of the Dealer/ Dealer’s representative : __________

Name of the Dealer/ Dealer’s representative: ______________
Seal/rubber stamp of the RO: ________________________
Place and Date : ___________________
Sample drawn by:
Signature : ___________________
Name : ___________________
Designation : ___________________
Oil Company : ___________________