Laserfiche WebLink
<br />I -. ) 211 ) -.1 ---1. r ) 3 Ck <br />t. 1 Z- 51V1 14YPLL ? -. lAY P?I? ? <br /> 07530 DI <br />•. COMMODITY CODE 6. PROOUCT COL?ECTEDI <br />7. IDENTIFICATION (Quote Pwtinent Labe tnd Includlnd Firm Naas and Addreae) <br />N'oAe-,r C? ?o_Ut tr" f -Diu J, <br />-c_ 2 0 OF <br /> <br />e.EMBARGO <br />CY <br />D. COLL. AGEN . INSP. NO. <br />10 11. COUNTY 12. C. F. NO. 13i ACTIVIT Y: <br />Q YES Q NO b. PROBLEM C. TIME (HR3 <br />14. MFG CONTROL CODES (Labels, Pkg. and ShlPPtng ConWnete) 1 <br /> <br />IS&. REASON FOR COL ECTION (Indicate A? Iya)a DesLed And Document 15 b. CODE <br />I <br />o X 2-?.s? <br />T 6. RESPONSIBLE FIRM MnS.D to by <br />17. MANUFACTURER Name. Street Addreaa, City, Comty and State) <br />10. SHIPPER (Name, Street Addteea, City, Comty and State) III. DATE SHIPPED <br />20. DEALER (Name, Street Addreaa, City, Cowty and Sialo) <br />21a. SIZE OF LOT FROM WHICH SAMPLED 21b. EST. VALUE 22. RELATED SAMPLES <br /> S <br />27. DESCRIPTION OF SAMPLE AND METHOD OF COLLECTION (No. 6 Size of Units, etc.) <br />24. HOW PREPARED - <br />211. INSPECTOR'S IDENT ON PKG. AND/ORLABEL 26. INSPECTOR'S IDENT ON SEAL <br />27.,S PLC DELIVE RE O <br /> <br />C nl 211. D TE <br />r <br />, 'O 20. LAB. <br />?+ <br />.IL 30. LAB. W/SPLIT <br />SAMPLE SOa. ORIG. C/R <br />RECORDS TO: <br />31 REMARKS/MEMORANDUM <br />L~fl? D 0, <br />S <br />D <br /># <br />r? <br /> <br />3 F r <br /> <br /> <br />?v3kt <br />z Co fo{oclo I;v 2?? <br />eo F jr Ip <br />? <br />-o <br />3 <br /> <br /> F <br />k <br />C <br />o <br />G <br />) <br />. . y <br />k " <br />CQ <br />? <br />F s-.zo <br /> <br /> <br />. <br />I <br />C <br />1:? <br />a.' <br />NA <br />IF ADDITIONAL SFACS IS REQUIRED, ATTACH SEPARATE SHEET <br />12. SAMPLE COST C V B !7. INSPECTOR (Typed Ne=e and Signature) <br />C. <br />34. P. <br />s a o a <br />ES:MFD 17(REV)8-68-50 COLLECTION REPORT SAMPLE RECORD COPY 1 <br />COLORADO DEPARTMENT OF HEALTH <br />