The State Department of Justice shall provide a common reporting form for the substances in Section 11100 which contains at least the following information:
(a) Name of the substance.
(b) Quantity of the substance sold, transferred, or furnished.
(c) The date the substance was sold, transferred, or furnished.
(d) The name and address of the person buying or receiving such substance.
(e) The name and address of the manufacturer, wholesaler, retailer, or other person selling, transferring, or furnishing such substance.