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DEPARTMENT OF HEALTH AND HUMAN SERVICES
FOOD AND DRUG ADMINISTRATION
Certification
Change
(See Reverse of Part III for Instructions)
Cancellation
Renewal
Form Approved: OMB No. 0910-0021
Expiration Date: May 31, 2016
See Burden Statement on back of Part III.
SECTION I - COMPLETED BY STATE SHELLFISH CONTROL AUTHORITY
2.
CERTIFICATION
1. SHELLFISH DEALER / SHIPPER (Name)
a) CERTIFICATE NUMBER
b) DATE CERTIFIED
c) STATE
d) EXPIRATION DATE
FACILITY ADDRESS (Include Street No., City, State, & ZIP)
MAILING ADDRESS (If different than above)
TELEPHONE
(
e) CATEGORY SYMBOL
)
DP - Depuration
RP - Repacker
RS - Reshipper
SP - Shucker-Packer
SS - Shell Stock Shipper
AQ - Aquaculture
WS - Wet Storage
PHP - Post Harvest
Processor
3. DATE OF ON-SITE INSPECTION
4. STATE SHELLFISH STANDARDIZATION INSPECTOR (Print
Name)
6. CANCELLATION DATE
7. REASON FOR CANCELLATION (Check One)
Decertification
5. EXPIRATION DATE OF INSPECTOR'S
STANDARDIZATION
Out of Business
Other (Please Specify)
8. a) STATE SHELLFISH CONTROL AUTHORITY
DESIGNEE (Print Name)
c) DATE CERTIFICATE SENT TO FDA
b) SIGNATURE
SECTION II - COMPLETED BY DIVISION OF COOPERATIVE PROGRAMS - FDA
9. DATE CERTIFICATE RECEIVED
10. DATE CERTIFICATE PUBLISHED
THIS CERTIFICATE MUST BE KEPT ON FILE FOR A PERIOD OF TWO (2) YEARS.
FORM FDA 3038 (6/13)
(Replaces Forms FDA 3038b and FDA 3038c which are obsolete.)
PART 1 - HFS-625
INTERSTATE SHELLFISH
DEALER'S CERTIFICATE
PSC Publishing Services (301) 443-6740
EF
(Check One)
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FOOD AND DRUG ADMINISTRATION
Certification
Change
(See Reverse of Part III for Instructions)
Cancellation
Renewal
Form Approved: OMB No. 0910-0021
Expiration Date: May 31, 2016
See Burden Statement on back of Part III.
SECTION I - COMPLETED BY STATE SHELLFISH CONTROL AUTHORITY
2.
CERTIFICATION
1. SHELLFISH DEALER / SHIPPER (Name)
a) CERTIFICATE NUMBER
b) DATE CERTIFIED
c) STATE
d) EXPIRATION DATE
FACILITY ADDRESS (Include Street No., City, State, & ZIP)
MAILING ADDRESS (If different than above)
TELEPHONE
(
e) CATEGORY SYMBOL
)
DP - Depuration
RP - Repacker
RS - Reshipper
SP - Shucker-Packer
SS - Shell Stock Shipper
AQ - Aquaculture
WS - Wet Storage
PHP - Post Harvest
Processor
3. DATE OF ON-SITE INSPECTION
4. STATE SHELLFISH STANDARDIZATION INSPECTOR (Print
Name)
6. CANCELLATION DATE
7. REASON FOR CANCELLATION (Check One)
Decertification
5. EXPIRATION DATE OF INSPECTOR'S
STANDARDIZATION
Out of Business
Other (Please Specify)
8. a) STATE SHELLFISH CONTROL AUTHORITY
DESIGNEE (Print Name)
b) SIGNATURE
c) DATE CERTIFICATE SENT TO FDA
SECTION II - COMPLETED BY DIVISION OF COOPERATIVE PROGRAMS - FDA
9. DATE CERTIFICATE RECEIVED
10. DATE CERTIFICATE PUBLISHED
THIS CERTIFICATE MUST BE KEPT ON FILE FOR A PERIOD OF TWO (2) YEARS.
FORM FDA 3038 (6/13)
(Replaces Forms FDA 3038b and FDA 3038c which are obsolete.)
PART 2 - REGIONAL SHELLFISH SPECIALIST
INTERSTATE SHELLFISH
DEALER'S CERTIFICATE
(Check One)
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FOOD AND DRUG ADMINISTRATION
Certification
Change
(See Reverse of Part III for Instructions)
Cancellation
Renewal
Form Approved: OMB No. 0910-0021
Expiration Date: May 31, 2016
See Burden Statement on back of Part III.
SECTION I - COMPLETED BY STATE SHELLFISH CONTROL AUTHORITY
2.
CERTIFICATION
1. SHELLFISH DEALER / SHIPPER (Name)
a) CERTIFICATE NUMBER
b) DATE CERTIFIED
c) STATE
d) EXPIRATION DATE
FACILITY ADDRESS (Include Street No., City, State, & ZIP)
MAILING ADDRESS (If different than above)
TELEPHONE
(
e) CATEGORY SYMBOL
)
DP - Depuration
RP - Repacker
RS - Reshipper
SP - Shucker-Packer
SS - Shell Stock Shipper
AQ - Aquaculture
WS - Wet Storage
PHP - Post Harvest
Processor
3. DATE OF ON-SITE INSPECTION
4. STATE SHELLFISH STANDARDIZATION INSPECTOR (Print
Name)
6. CANCELLATION DATE
7. REASON FOR CANCELLATION (Check One)
5. EXPIRATION DATE OF INSPECTOR'S
STANDARDIZATION
Decertification
Out of Business
Other (Please Specify)
8. a) STATE SHELLFISH CONTROL AUTHORITY
DESIGNEE (Print Name)
b) SIGNATURE
c) DATE CERTIFICATE SENT TO FDA
SECTION II - COMPLETED BY DIVISION OF COOPERATIVE PROGRAMS - FDA
9. DATE CERTIFICATE RECEIVED
10. DATE CERTIFICATE PUBLISHED
THIS CERTIFICATE MUST BE KEPT ON FILE FOR A PERIOD OF TWO (2) YEARS.
FORM FDA 3038 (6/13)
(Replaces Forms FDA 3038b and FDA 3038c which are obsolete.)
PART 3 - STATE REGULATORY AGENCY
INTERSTATE SHELLFISH
DEALER'S CERTIFICATE
Instructions for completing Form FDA 3038 (6/13)
Section I - Completed by State Shellfish Certification Agency
1. Shellfish Dealer/Shipper: Name, Facility Address, Street
No., City/Town, State, ZIP, and Telephone. Include mailing
address if different than physical location of facility.
2. Certification: Certificate Number - a unique number assigned to each certified shellfish dealer; Date Certified;
State - two letter State Code; Expiration Date - date
certificate expires; Category Symbol - two or three letter
code designating dealer process.
3. Date of On-Site Inspection: Date plant was inspected for
certification.
6. Cancellation Date: Date firm has been either decertified or
recommended for delisting.
7. Reason for Cancellation: Check applicable box. Other
denotes voluntary or seasonal suspension of activities.
8.a) State Shellfish Control Authority designee: Print name to
validate signature block.
8.b) Signature of designee
8.c) Date certificate sent to FDA
4. State Shellfish Standardization Inspector: Print name of
Inspector who conducted the on-site inspection.
5. Expiration Date of Inspector's Standardization: Print date
the inspector's standardization will expire.
Section II - Completed by Division of Cooperative Programs - FDA
This section applies only to requirements of the Paperwork Reduction Act of 1995.
Public reporting burden for this collection of information is estimated to average 6 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. Send comments
regarding this burden estimate or any other aspect of the collection of information, including suggestions for reducing this burden to:
Department of Health and Human Services
Food and Drug Administration
Office of Chief Information Officer
[email protected]
Do NOT send your completed
form to the PRA Staff email
address to the left.
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB
control number.
| File Type | application/pdf |
| File Title | FORM FDA 3038 |
| Subject | Interstate Shellfish Dealer's Certificate |
| Author | PSC Publishing Services |
| File Modified | 2016-03-02 |
| File Created | 2007-03-16 |