VS 16-25 Application for Approval or Report of Inspection of Esta

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not
required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB
control number for this information collection is 0579-0015. The time required to complete this information
collection is estimated to average 2 hours per response, including the time for reviewing instructions, search existing
data sources, gathering and maintaining the data needed,and completing and reviewing the collection of information.

U.S. DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
VETERINARY SERVICES
RIVERDALE, MARYLAND 20737

APPLICATION FOR APPROVAL OR REPORT OF
INSPECTION OF ESTABLISHMENT HANDLING
RESTRICTED ANIMAL BYPRODUCTS OR CONTROLLED

No inspection or storage in an approved establishment can be made unless
a completed application has been received (9 CFR 93, 94, and 95).
FORM APPROVED OMB NO. 0579-0015

EXP. DATE

1. CURRENT INSPECTION DATE

2. LAST INSPECTION DATE

3. CURRENT AGREEMENT DATE

4. AGREEMENT EXPIRATION DATE

6. BYPRODUCTS TO BE RECEIVED BY

5. AREA OFFICE

RAIL

TRUCK

Submit an original and one copy to address above. The
original will be returned, the copy retained.

INSTRUCTIONS:
7. INSPECTIONS
INITIAL

CONTAINER OR
TRAILER

8. TRUCK OR RAIL SHIPPING ADDRESS
REINSPECTION

SPECIAL

ANIMAL

9. NAME AND MAILING ADDRESS OF ESTABLISHMENT
(Include ZIP Code)
10. COUNTRIES WHERE RESTRICTED PRODUCTS ORIGINATE

Telephone No. (

)

11. APPROXIMATE YEARLY VOLUME

GPS NO.
12A. NAME OF CONTACT AT ESTABLISHMENT

12B. TITLE OF CONTACT PERSON AT ESTABLISHMENT

13. NAME EACH RESTRICTED BYPRODUCT OR MATERIAL TO
BE HANDLED

14. METHOD(S) USED FOR SEWAGE AND EFFLUENT DISPOSAL

15. IS THERE ADEQUATE SEPARATION OF RESTRICTED/
UNRESTRICTED PRODUCT(S)
YES

NO

17. HOW ARE BYPRODUCTS TO BE MOVED TO STORAGE
FACILITY

16. IN YOUR OPINION DOES THIS SEPARATION MEET APHIS
REQUIREMENTS
(If no, explain in remarks, Block 25.)
YES
NO
18. HOW ARE BYPRODUCTS TO BE MOVED TO PROCESSING AREA

19. IF SEPARATE STORAGE FACILITIES ARE MAINTAINED DESCRIBE CAPACITY AND CONSTRUCTION MATERIAL

20. DESCRIBE IS DETAIL PROCESSING AND/OR DISINFECTION OF THE RESTRICTED MATERIAL (Do not site VS Memo.)

21. METHODS USED TO CONTROL PROCEDURE IN ITEM 20 (Consider temperature, time recording devices, vacuum or pressure gages,
chemical analysis, pH determinations.)

22. WHAT PERSONS SUPERVISED THE WORK IN ITEM 20 OR
CONDUCTED TESTS

23. WHAT DISINFECTANT WAS USED ON CARS, TRUCKS, ETC.

24. WHAT METHOD WAS USED TO CLEAN AND DISINFECT (Include disinfection or destruction of containers.)

25. REMARKS

26. SIGNATURE OF INSPECTOR

29. RECOMMEND APPROVAL (Signature)

27. PLEASE TYPE OR PRINT NAME

30. DATE

Area Veterinarian-in-Charge

VS FORM 16-25

28. TITLE

31. APPROVED BY (Signature)

Staff Veterinarian Import-Export
Previous editions are obsolete.

32. DATE