Form 5200-15 Hours of Operations

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 0583-xxxx. The time
required to complete this information collection is estimated to average 20 minutes 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.
U. S. DEPARTMENT OF AGRICULTURE
FOOD SAFETY AND INSPECTION SERVICE

HOURS OF OPERATION REQUEST/APPROVAL
1. NAME OF APPLICANT

2. DATE OF REQUEST

3. DISTRICT / IID-HEADQUARTER OFFICE

4. MAILING ADDRESS OF APPLICANT

New (Attach to application form)
Update or Revision

HOURS OF OFFICIAL INSPECTION OPERATIONS REQUESTED - SHIFT I
DAY OF WEEK

SUNDAY

MONDAY

TUESDAY

WEDNESDAY

THURSDAY

FRIDAY

SATURDAY

Start Time
Lunch
Break Start
Lunch
Break End
End Time

HOURS OF OFFICIAL INSPECTION OPERATIONS REQUESTED - SHIFT 2
DAY OF WEEK

SUNDAY

MONDAY

TUESDAY

WEDNESDAY

THURSDAY

FRIDAY

SATURDAY

Start Time
Lunch
Break Start
Lunch
Break End
End Time
5. SIGNATURE OF APPLICANT

6. PRINTED NAME

HOURS OF OFFICIAL INSPECTION OPERATIONS GRANTED - SHIFT I
DAY OF WEEK

SUNDAY

MONDAY

TUESDAY

WEDNESDAY

THURSDAY

FRIDAY

SATURDAY

Start Time
Lunch
Break Start
Lunch
Break End
End Time

HOURS OF OFFICIAL INSPECTION OPERATIONS GRANTED - SHIFT 2
DAY OF WEEK

SUNDAY

MONDAY

TUESDAY

WEDNESDAY

THURSDAY

FRIDAY

SATURDAY

Start Time
Lunch
Break Start
Lunch
Break End
End Time
7. PRINT NAME OF DISTRICT/ IID - HEADQUARTER MANAGER

FSIS FORM 5200-15 (2/15/2011)

8. SIGNATURE OF DISTRICT/ IID-HEADQUARTER MANAGER

9. DATE