VS 13-15 Application for Licensing of Garbage Treatment Facility

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 is 0579-0065. The time required to complete this information collection is estimated to average
.16 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
0579-0065
EXP. Date
XX/XXXX

No facility can be licensed for treatment or garbage until an application has been submitted and approved, (PL 90-468 and 9 CFR 166)

U.S, DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE

1. LICENSE NO.

FOR USOA-VS USE ONLY
2. COUNTY

APPLICATION FOR LICENSING OF GARBAGE TREATMENT FACILITY
INSTRUCTIONS: Please type or print clearly. Complete Items 3 through 10 and send parts 1 and 2 to your VS area office.
Retain part 3 for your records. A separate application is needed for each treatment facility.
3. NAME OF APPLICANT (First Name, MI, Last Name)

4. PHONE NUMBER (Include area code)

5. NAME AND MAILING ADDRESS OF YOUR TREATMENT FACILITY
(Include ZIP code)

6. ADDRESS WHERE YOU MAY BE CONTACTED IN PERSON
(If different from item 5)

7. LOCATION OF YOUR TREATMENT FACILITY (If same as item 5 or 6, indicate which address. If your facility is at a location NOT having a street address, give directions
on how to reach the facility.)

If more space Is needed “X”· box

and continue on reverse.

8. SOURCE(S) OF GARBAGE RECEIVED

I certify that this Information Is true, accurate, and complete to the bell of my knowledge and belief.
9. SIGNATURE OF APPLICANT

10. DATE OF APPLICATION

TO BE COMPLETED AT THE TIME OF THE PRELICENSING INSPECTION
This Is to certify that I have received a copy of the Swine Health Protection Act (PL 96-468) and regulations (9 CFR, Part 166), that I understand the requirements of the Act
and regulations, that I agree to comply with the Act and regulations, and that I agree to give access during normal business hours to inspectors authorized by the Department.
I further agree to dispose of garbage that is not to be fed to swine, and materials In association with such garbage, in a manner consistent with applicable environmental
guidelines.
11. SIGNATURE

12. DATE

APPROVAL
Assignment of a license number (item 1 above) and signature of the approving official constitutes your license to operate a garbage treatment facility.
13. SIGNATURE OF APPROVING OFFICIAL

VS FORM 13-15
JUN 2011

14. DATE APPROVED

Previous edition may be used