Form VS 16-25 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 collection is 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
0579-0245
Exp.: XX/XXXX

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
APPLICATION FOR APPROVAL OR REPORT OF INSPECTION OF
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
ESTABLISHMENT HANDLING RESTRICTED ANIMAL BYPRODUCTS OR
VETERINARY SERVICES
CONTROLLED MATERIALS
RIVERDALE, MD
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

7. INSPECTIONS
INITIAL

TRUCK

CONTAINER OR TRAILER

8. TRUCK OR RAIL SHIPPING ADDRESS
REINSPECTION

SPECIAL

ANNUAL

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?

16. IN YOUR OPINION DOES THIS SEPARATION MEET APHIS REQUIREMENTS?

YES

NO

YES

17. HOW ARE BYPRODUCTS TO BE MOVED TO STORAGE FACILITY?

NO (If no, explain in remarks, Block 25.)

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

29. RECOMMEND APPROVAL (Signature)

VS 16-25
JUL 2012

27. PLEASE TYPE OR PRINT NAME

30. DATE

28. TITLE

31. STAFF VETERINARIAN IMPORT/EXPORT (Signature)

32. DATE