GAS/DIESEL

ANALYSIS
416 E. Pettit Ave., Ft. Wayne, IN 46806
(260)744-2380 www.blackstone-labs.com

Name:
Unit ID:
Address: (What do you want to call it?)

Sample date:
City State Zip
Mi/Hr/Km on oil:
Contact: (choose one)

Email: Mi/Hr/Km on engine:

(choose one)
Phone:
Oil added between changes: qts.
Engine Make:
Oil type:
Model:
Vehicle Year: Fuel Gas Leaded E85
Type: Diesel Other:
Make:
For Office Use Only
Model:

Please send more sample containers.

Credit card Check Prepaid sample

Payment

Use card on file Check # I entered my card info online

Use card below Order #
This is one of my discount
Name: (bulk) samples
Card number:
Exp. date:
Billing address (if different):

Was the oil changed when the sample was taken? Yes No
Are you interested in extended oil use? Yes No
Have you used any additives? (list below) Yes No
Would you like a TBN (additional cost of $10)? Yes No
(A TBN measures the amount of active additive present and is only run on engine oil.)

Comments or questions:

For Office Use Only

Need a different oil slip? Go to https://www.blackstone-labs.com/services/oil-slips/