According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond

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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, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

OMB APPROVED
0579-0015
EXP Date XX/XXXX
No inspection or storage in an approved establishment can be made unless a completed application has been received (9 CFR 93, 94 and 95).
INSTRUCTIONS:  Submit an original and one copy to address below.  The original will be returned, the copy retained.
UNITED STATES DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
VETERINARY SERVICES
RIVERDALE, MD
APPLICATION FOR APPROVAL OR REPORT OF INSPECTION OF ESTABLISHMENT HANDLING RESTRICTED ANIMAL BYPRODUCTS OR CONTROLLED MATERIALS
1.  CURRENT INSPECTION DATE
2.  LAST INSPECTION DATE
3.  CURRENT AGREEMENT DATE
4.  AGREEMENT EXPIRATION DATE
5.  AREA OFFICE
6.  BYPRODUCTS TO BE RECEIVED BY
          RAIL         TRUCK          CONTAINER OR TRAILER
7.  INSPECTIONS

  INITIAL   REINSPECTION   SPECIAL   ANNUAL
8.  TRUCK OR RAIL SHIPPING ADDRESS
9.  NAME AND MAILING ADDRESS OF ESTABLISHMENT (Include ZIP Code)





10.  COUNTRIES WHERE RESTRICTED PRODUCTS ORIGINATE

TELEPHONE NUNBER  (    )
GPS NUMBER


DUN AND BRADSTREET NUMBER


12A.  NAME OF CONTACT AT ESTABLISHMENT
11.  APPROXIMATE YEARLY VOLUME

13.  NAME EACH RESTRICTED BYPRODUCT OR MATERIAL TO BE HANDLED
        PRODUCT(S


12B.  TITLE OF CONTACT PERSON AT ESTABLISHMENT


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

15.  IS THERE ADEQUATE SEPARATION OF RESTRICTED/UNRESTRICTED                                                                                                                    
                                                  YES      NO
16.  IN YOUR OPINION DOES THIS SEPARATION MEET APHIS REQUIREMENTS
         YES   NO (If no, explain in remarks, Block 25.)
17.  HOW ARE BYPRODUCTS TO BE MOVED TO STORAGE FACILITY

18.  HOW ARE BYPRODUCTS TO BE MOVED TO PROCESSING AREA
19.  IF SEPARATE STORAGE FACILITIES ARE MAINTAINED DESCRIBE CAPACITY AND CONSTRUCTION MATERIAL


20.  DESCRIBE IN 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, TRUCK, ETC.?

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


25.  REMARKS





26.  SIGNATURE OF INSPECTOR

27.  PLEASE TYPE OR PRINT NAME
28.  TITLE
29.  RECOMMEND APPROVAL (Signature)

30.  DATE
31.  STAFF VETERINARIAN IMPORT/EXPORT  (Signature)
32.  DATE

VS 16-25
NOV 2009