When a sample of specially denatured spirits is withdrawn from a dealer's premises, that dealer shall attach a label to the sample which shows the following information:

(a) The word “Sample”;

(b) The dealer's name, address, and permit number;

(c) The words “Specially Denatured Alcohol” or “Specially Denatured Rum”;

(d) The quantity; and

(e) The formula number.