FORM DEA-106 (Sep. 2007) Pg. 2

LIST OF CONTROLLED SUBSTANCES LOST

FORM DEA-106 (Sep. 2007) Pg. 2
Trade Name of Substance or Preparation
Examples

Desoxyn

NDC Number

Name of Controlled Substance in Preparation

Dosage Strength

Dosage Form

Total Quantity
Lost or Stolen

00074-3377-01

Methamphetamine Hydrochloride

5 mg

Tablets

300

Demerol

00409-1181-30

Meperidine Hydrochloride

50 mg/ml

Vial

150 ml

Robitussin A-C

00031-8674-25

Codeine Phosphate

2 mg/cc

Liquid

5676 ml

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(This is new information)

6.
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8.

(This is the same information
collected before but split into
three columns instead of two)

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Express Quantity
in Dosage Units
or Milliliters
for Liquids

I certify that the foregoing information is correct to the best of my knowledge and belief.

Signature

Title

Date