Form vs 10-5 vs 10-5 USDA LISTED SLAUGHTER FACILITY INSPECTION REPORT

According to the Paperwork Reduction Act of 1995, no persons are required to re spond to a collection of information unless it displays a valid OMB control nu mber. The valid
OMB control number for this information collection is 0579-0212. The time requ ired to complete this information collection is estimated to average .083 hours per response,
including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the co llection of
information.

UNITED STATES DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
VETERINARY SERVICES
Slaughter Establishment's Number:

OMB APPROVED
0579-0212

USDA LISTED SLAUGHTER FACILITY INSPECTION REPORT

Federal/State Inspection:

Premises ID Number:

GPS Coordomates (where driveway meets the street)
Latitude

Status of Slaughter Establish:

Listing required

Yes

Longitude

If yes,

No

Pending

Listed

Facility Name:
Name of Legally Responsible Person:
Contact Person's Name:
Telephone Number:
City:

Fax Number:

E-Mail:

State:

County/Parish:

City:

State:

Zip Code:

Facility Manager:

Telephone Number:

Mail Address;

Fax Number:

E-Mail

Animals Slaughtered/Processed per Week (average number)
Cattle:

Finish

Bison:

Cull Cows
Swine:

Finish Hogs

Cervids:

Sows & Boars
Sheep:

Deer
Elk

Finish Lambs
Cull Sheep
% Black-Faced

Goats:

Finish Kids

Exotics (list):

Cull Goats

Other Species (list):

APHIS Surveillance Sampling Program (Continuous or Periodic):
Disease(s) for which samples are collected:
Facility Inspection:
Access:

APHIS or its representatives are granted access to the facility and production.

Work Area: Facility provides a satisfactory, well-lit, and safe working area to collect samples.
Facility provides tables and equipment for sample collection, testing, and pack ing for shipping.
Records:

All livestock or livestock carcasses are properly identified, and carcasses an be connected to animal ID and owner.
Facility maintains records (i.e., weigh tickets, sales slips, kill sheets, etc.) for 2 years

Office:

Facility provides suitable office space, including furniture, light, temperature control, etc.
Office is appropriately located, properly ventilated, and has lockers for APHIS or its representatives to use.

Sanitary:

Facility maintains an adequate supply of disinfectant and serviceable equipment for cleaning and disinfection.
Facility is maintaine in a clean and sanitary condition.

VS FORM 10-5
(MAR 2007)

Yes

No

Comments:

District 05, Alameda, CA,
(510) 337-5000

Responsible for State of California

District 65, Albany, NY
(518) 452-6870,

Responsible for Connecticut, Maine, Massachusetts, New Hampshire, New York, Rhode Island, Vermont

District 85, Atlanta, GA,
(404) 562-5900

Responsible for Florida, Georgia, Puerto Rico, Virgin Islands

District 75, Beltsville, MD
(301) 504-2136

Responsible for Delaware, Washington DC, Maryland, Virginia, West Virginia

District 15, Boulder, CO
(303) 497-5411

Responsible for Arizona, Colorado, New Mexico, Nevada, Utah, Alaska, American Samoa, Hawaii, Idaho, Oregon, Washington

District 50, Chicago, IL
(630) 620-7474

Responsible for Illinois, Indiana, Ohio

District 40, Dallas, TX
(214) 767-9116

Responsible for Texas

District 25, Des Moines, IA
(515) 727-8960

Responsible for Iowa, Nebraska

District 90, Jackson, MS
(601) 965-4312

Responsible for Alabama, Mississippi, Tennessee

District 30, Lawrence, KS
(785) 841-5600

Responsible for Kansas, Missouri

District 45, Madison, WI
(608) 240-4080

Responsible for Michigan, Wisconsin

District 20, Minneapolis, MN
(612) 370-2400

Responsible for Minnesota, Montana, North Dakota, South Dakota, Wyoming

District 60, Philadelphia, PA
(215) 597-4219

Responsible for Pennsylvania, New Jersey

District 80, Raleigh, NC
(919) 844-8400

Responsible for North Carolina, South Carolina, Kentucky

District 35, Springdale, AR
(479) 751-8412

Responsible for Arkansas, Louisiana, Oklahoma

VS FORM 10-5
REVERSE