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

Highly Pathogenic Avian Influenza, All Subtypes, and Newcastle Disease;Additional Restrictions

VS 16-25 Jul 2012

Private Sector

OMB: 0579-0245

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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 numbers for these information collections are 0579-0015 and 0579-0245. 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 and 0579-0245

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


11. APPROXIMATE YEARLY VOLUME


13. NAME EACH RESTRICTED PRODUCT, BYPRODUCT, OR MATERIAL TO BE

HANDLED

12A. NAME OF CONTACT AT ESTABLISHMENT



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 gauges, chemical analysis, ph

determinations.)


22. WHAT PERSON(S) SUPERVISED THE WORK IN ITEM 20 OR CONDUCTED TESTS?




23. WHAT DISINFECTANT WAS USED ON CAR, 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

JUL 2012

File Typeapplication/msword
File TitleAccording to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond
AuthorKhbrown
Last Modified ByHardy, Kimberly A - APHIS
File Modified2013-10-29
File Created2012-07-16

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