VS 16-25 Application for Approval or Report of Inspection of Esta

Restricted, Prohibited, and Controlled Importation of Animal and Poultry Products and ByProducts into the United States

VS 16-25 Aug 2009

Importation of Restricted and Controlled Animal and Poultry Products and Byproducts, Organisms, and Vectors into the U.S. - Not For Profit

OMB: 0579-0015

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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 0579-0015. 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

0579-0015

EXP Date 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

ANIMAL AND PLANT HEALTH INSPECTION SERVICE

VETERINARY SERVICES

RIVERDALE, MD

APPLICATION FOR APPROVAL OR REPORT OF INSPECTION OF ESTABLISHMENT HANDLING RESTRICTED ANIMAL BYPRODUCTS OR CONTROLLED MATERIALS

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 TRUCK CONTAINER OR TRAILER

7. INSPECTIONS


INITIAL REINSPECTION SPECIAL ANNUAL

8. TRUCK OR RAIL SHIPPING ADDRESS

9. NAME AND MAILING ADDRESS OF ESTABLISHMENT (Include ZIP Code)




10. COUNTRIES WHERE RESTRICTED PRODUCTS ORIGINATE


TELEPHONE NUNBER ( )

GPS NUMBER


DUN AND BRADSTREET NUMBER


12A. NAME OF CONTACT AT ESTABLISHMENT

11. APPROXIMATE YEARLY VOLUME


13. NAME EACH RESTRICTED BYPRODUCT OR MATERIAL TO BE HANDLED

PRODUCT(S



12B. TITLE OF CONTACT PERSON AT ESTABLISHMENT


14. METHOD(S) USED FOR SEWAGE AND EFFLUENT DISPOSAL


15. IS THERE ADEQUATE SEPARATION OF RESTRICTED/UNRESTRICTED

YES NO

16. IN YOUR OPINION DOES THIS SEPARATION MEET APHIS REQUIREMENTS

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

17. HOW ARE BYPRODUCTS TO BE MOVED TO STORAGE FACILITY


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 gages, chemical analysis, ph

determinations.)

22. WHAT PERSONS SUPERVISED THE WORK IN ITEM 20 OR CONDUCTED TESTS

23. WHAT DISINFECTANT WAS USED ON CARS, TRUCK, ETC.?


24. WHAT METHOD WAS USED TO CLEAN AND DISINFECT (Include disinfection or destruction of containers)



25. REMARKS






26. SIGNATURE OF INSPECTOR


27. PLEASE TYPE OR PRINT NAME

28. TITLE

29. RECOMMEND APPROVAL (Signature)


30. DATE

31. STAFF VETERINARIAN IMPORT/EXPORT (Signature)

32. DATE


VS 16-25

NOV 2009

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