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<br />n q 1 qo D <br />i <br />_ <br />x <br />1 i <br />? <br />a. COU?IOOITY CODE 0. PAODUCT COLLECTEDIf 6. DATE COLLECTED <br /> ?I sr l <br />7. 10EN TIFICAT ION (Quota Port)nent Labeling lncludlry Flra, Naas and Addreaa) <br />?? ?CConn2 ?? <br />w 4?? x 3c?? <br /> <br />S. EMBARGO O. COLL. AGENCY 10, INSP. NO. II.000NTY 12. C. F. NO. 13a- ACTIVITY' <br />Q YE] ONO 1 6. PROBLEM C. TIME (HR] <br />14, MFG CONTROL COOES (Labels. Pkg, and Shipping Containers) I <br /> <br />15a. REASON FOR COLLECTION (Indicate Analysts Desired end Document Aas/gnmsnt) 16 b. CODE <br />7zxl-rp -tr'Nc- 6. RESPONSIBLE FIR>a (M S.D t? by <br />17. MANUFACTURER (Name, Street Address, City, CountT end State) <br />1s. ]RIPPER (,tame. Street Addraas, CRy, Cawnty and State) 19. DATE SHIPPED <br />20. DEALER (.Name, .Street Address, City, County and State) <br />tie. SIZE Or LOT FROM WHICH SAMPLED 21b, EST. VALUE 22. RELATED SAMPLES <br />S <br />23. DESCRIPTION OF SAMPLE AND METHOD OF COLLECTION (No. 6 Size of Units, etc.) <br />24. HOW PREPARED <br />23. IN3PECTOR'3 (DENT ON PKG. AND/OR LABEL 26. IN3PECTOR'3 (DENT ON SEAL <br />MPLE GELIVE % 'TO <br />27. 20. DAT <br />22. LAB. 7 <br />30. LAD. w/SPLIT <br />SAMPLE <br />30s, ORIG. C/R <br />ORECORDS RG. / 70: <br />7 0 <br />31. EMARKS/MEMORANDUM <br />Ao---) I 7-E, I 'vtMGt Z <br />p-- (,4 <br />? <br />L"Li 71- <br /> <br />71 <br />1?????I <br /> <br />L <br />S ee <br />IF ADDITIONAL SPACE IS REQUIRED, ATTACH SEPARATE SHEET <br />32. SAMPLE COST C V B 33. INSPECTOR (Typed Name and Signature) 34. P. C. <br />$ p p O <br />ES:MFD O(REV)8-68-50 COLLECTION REPORT <br />COLORADO DEPARTMENT OF HEALTH <br />Analyst ?9i?i1"1L2-.?7/