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<br />Y[wR MO DAY YEAR MO DAY
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<br />M I N U H Form Approved.
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<br />F - FI N A Proval expires 6-30-91.
<br />SURFACE i;UNOFF TROUT CHi(
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<br /> (J Card Onry) QUANTITY OR LOAOINO (i Card Only) OU ALITY OR CONCENTRATION
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<br />(69-7p)
<br />.. 6AMPLE 00090 :09rf 00 -~ - -. ~ 0001¢Y,e ~ ( I2
<br /> MEASUREMENT .,_
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<br />HON, TOTAL eAMPL[ A0040 0030 - 4TxO0p ~ ( Iy
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<br />LSSULYED MEASUREMENT - -
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<br />~,(N~ SuPT. MIFICAM PENALTI[5 FOR SU~1rnIN0 FALS[ INFORMATIOry; NCLUDNG
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