Report for Partially Regulated Distributing Plants

USDA, AMS, Dairy Programs
Market Administrator
1550 North Brown Rd., Ste 120,
Lawrenceville, GA 30043
(770) 682-2501
RECORD OF MILK PRODUCTS DUMPED OR LOST

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 0581-0032.
The time required to complete this information collection is estimated to average .5 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.
The U.S. Department of Agriculture (USDA) prohibits
discrimination in all its programs and activities on the basis of
race, color, national origin, age, disability, and where
applicable, sex, marital status, familial status, parental status,
religion, sexual orientation, genetic information, political
beliefs, reprisal, or because all or part of an individual’s
income is derived from any public assistance program. (Not
all prohibited bases apply to all programs.) Persons with
disabilities who require alternative means for communication
of program information (Braille, large print, audiotape, etc.)
should contact USDA’s TARGET Center at (202) 720-2600
(voice and TDD). To file a complaint of discrimination, write
to USDA, Director, Office of Civil Rights, 1400 Independence
Avenue, S.W., Washington, D.C. 20250-9410, or call (800)
795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal
opportunity provider and employer.

Form Approved,
OMB No. 0581-0032

UNITED STATES DEPARTMENT of AGRICULTURE
AGRICULTURAL MARKETING SERVICE - DAIRY PROGRAMS
MARKET ADMINISTRATOR
Federal Orders 6 and 7
1550 North Brown Rd., Ste. 120, Lawrenceville, GA 30043
(770) 682-2501 Fax (770) 822-1038
www.fmmatlanta.com
email: [email protected]

RECORD OF MILK PRODUCTS DUMPED OR LOST
Instructions: To qualify for appropriate credit for dumped or lost product, notification must be made to the
Market Administrator’s office by telephone, fax, or email by the next business day. Please report dump
or loss to one of the phone numbers, fax numbers or email addresses listed above.

HANDLER NAME

LOCATION
(CITY/STATE)

DATE OF DUMP/LOSS

Where and how was product disposed?

TIME

(Please check description, explain if necessary)
Product dumped from batch tank, vat, silo or other measurable method.
Explain :

Product loss was not contained (accidental loss, quantity estimated through other methods).
Explain :

Product Description

Units of
Measure

Product Weight

Butterfat %

Butterfat Pounds

Handler Comments:

Handler Representative:
Name:

Date:

MA Representative Receiving Notification:
Name:
Comments:

MA Use Only
Date:

Month
Auditor
Date