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Department of Inspections, Appeals, and Licensing

susan.wennekamp@dia.iowa.gov

6200 Park Ave., Ste. 100 Des Moines, IA 50321

515.281.5944

Precursor Substances Transaction Report

Type of Transaction Reported

Transaction Date

Recipient Address

    Provider Address

      Name of Substance(s) Transferred/Sold

      Name of Substance(s) Transferred/Sold

      Name of Substance(s) Transferred/Sold

      Name of Substance(s) Transferred/Sold

      Name of Substance(s) Transferred/Sold

      Name of Substance(s) Transferred/Sold

      Business/Activity of Person or Business Reporting

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