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

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