VS 13-15 Application for Licensing of Garbage Treatment Facility

No facility can be licensed for treatment of garbage until an application
has been submitted and approved. (PL 96-468 and 9 CFR 166)

FORM APPROVED
OMB NO. 0579-0065

According to the Paperwork Reduction Act of 1995, no persons are required to re spond to a
collection of information unless it displays a valid OMB control number. The valid OMB control
number for this collection is 0579-0065. The time required to complete this in formation collection
is estimated to average .16 hours per response, including the time for reviewin g instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and
reviewing the collection of information.

U.S. DEPARTMENT OF AGRICULTURE

FOR USDA-VS USE ONLY

ANIMAL AND PLANT HEALTH INSPECTION SERVICE

APPLICATION FOR LICENSING OF GARBAGE TREATMENT FACILITY

1. LICENSE NO.

2. COUNTY

INSTRUCTIONS: Please type or print clearly. Complete items 3 through 10 and send parts 1 and 2 to your VS area office.
Retain part 3 for your records. A separate application is needed for each treatment facility.
3. NAME OF APPLICANT (First name, MI, Last name)

5. NAME AND MAILING ADDRESS OF YOUR TREATMENT FACILITY
(Include zip code)

4. PHONE NO. (Include area code)

6. ADDRESS WHERE YOU MAY BE CONTACTED IN PERSON (If different
from item 5)

7. LOCATION OF YOUR TREATMENT FACILITY (If same as item 5 or 6, indicate which address. If your facility is at a location NOT having a street address, give directions
on how to reach the facility.)

If more space is needed "X" box

and continue on reverse.

8. SOURCE(S) OF GARBAGE RECEIVED

I certify that this information is true, accurate, and complete to the best of my knowledge and belief.
9. SIGNATURE OF APPLICANT

10. DATE OF APPLICATION

TO BE COMPLETED AT THE TIME OF THE PRELICENSING INSPECTION
This is to certify that I have received a copy of the Swine Health Protection Act (PL 96-468) and regulations (9 CFR, Part 166), that I understand the require ments of the Act
and regulations, that I agree to comply with the Act and regulations, and that I agree to give access during normal business hours to inspectors authorized by the
Department. I further agree to dispose of garbage that is not to be fed to swine, and materials in association with such garbage, in a manner consistent with applicable
environmental guidelines.
11. SIGNATURE

12. DATE

APPROVAL
Assignment of a license number (item 1 above) and signature of the approving of ficial constitutes your license to operate a garbage treatment facility.
13. SIGNATURE OF APPROVING OFFICIAL

VS FORM 13-15
OCT 2004

14. DATE APPROVED

Previous edition may be used