VS Form 10-5 USDA Listed Slaughter or Rendering Facility Inspection R

According to the Paperwork Reduction Act of 1995, no persons are 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 0579-0212. The time required to complete this information collection is estimated to average .083 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.

UNITED STATES DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
VETERINARY SERVICES

USDA LISTED SLAUGHTER OR RENDERING FACILITY
INSPECTION REPORT

SLAUGHTER ESTABLISHMENT (FSIS) NUMBER

FEDERAL/STATE INSPECTION

PREMISES IDENTIFICATION NUMBER

NATIONAL PREMISES ID NUMBER

GPS COORDINATES (where driveway meets the road)
LATITUDE:

OMB APPROVED
0579-0212
XX/XXXX

SOURCE

LONGITUDE:

GPS

MAP

DOES THIS FACILITY RECEIVE LIVESTOCK, POULTRY, OR CARCASSES IN INTERSTATE COMMERCE?

YES

NO

FACILITY NAME
NAME OF LEGALLY RESPONSIBLE PERSON
NAME OF CONTACT PERSON

TELEPHONE NUMBER

PHYSICAL ADDRESS (include county)

FAX NUMBER
EMAIL ADDRESS

MAILING ADDRESS
FACILITY MANAGER

TELEPHONE NUMBER

EMAIL ADDRESS

FAX NUMBER

FSIS INSPECTOR-IN-CHARGE

TELEPHONE NUMBER

EMAIL ADDRESS

APHIS INSPECTOR

TELEPHONE NUMBER

EMAIL ADDRESS

INSPECTION DATE

ANIMALS SLAUGHTERED/PROCESSED PER WEEK (AVERAGE)
CATTLE:
FINISH

SHEEP:
LAMBS (<18 MONTHS)

GOATS:
KIDS (<18 MONTHS)

BISON

CATTLE:
CULL COWS

SHEEP:
MATURE (>18 MONTHS)

GOATS:
MATURE (>18 MONTHS)

EXOTICS (list)

SWINE:
FINISH HOGS

SHEEP:
% BLACK-FACED

CERVID:
DEER

SWINE:
SOWS AND BOARS

POULTRY

CERVID:
ELK

OTHER SPECIES

APHIS SURVEILLANCE SAMPLING PROGRAM (Continuous or Periodic)
DISEASE(S) FOR WHICH SAMPLES ARE COLLECTED

FACILITY INSPECTION
AREA

CRITERIA

Access

1 - APHIS or its representatives are granted access to the facility and production.

Work
Area

2 - Facility provides a satisfactory, well-lit, and safe working area to collect samples..

Records

Office

Sanitary

COMPLIANCE
YES

NO

YES

NO

3 - Facility provides tables and equipment for sample collection, testing, and packaging for
shipping.

YES

NO

4 - All livestock, poultry, or carcasses are properly identified, and carcasses can be
connected to animal ID and owner.

YES

NO

5 - Facility maintains records (i.e., weigh tickets, sales slips, kill sheets, etc.) for 2 years for
poultry and swine, and 5 years for cattle, bison, equines, sheep, goats, and cervid.

YES

NO

6 - Facility provides suitable office space, including furniture, light, temperature control, etc.

YES

NO

7 - Office is appropriately located, properly ventilated, and has lockers for APHIS or its
representatives to use.

YES

NO

8 - Facility maintains an adequate supply of disinfectant and serviceable equipment for
cleaning and disinfection.

YES

NO

YES

NO

9 - Facility is maintained in a clean and sanitary condition.

VS FORM 10-5
MAY 2017

COMMENTS

District 05, Alameda, CA,
(510) 337-5000

Responsible for State of California

District 65, Albany, NY
(518) 452-6870,

Responsible for Connecticut, Maine, Massachusetts, New Hampshire, New York, Rhode Island, Vermont

District 85, Atlanta, GA,
(404) 562-5900

Responsible for Florida, Georgia, Puerto Rico, Virgin Islands

District 75, Beltsville, MD
(301) 504-2136

Responsible for Delaware, Washington DC, Maryland, Virginia, West Virginia

District 15, Boulder, CO
(303) 497-5411

Responsible for Arizona, Colorado, New Mexico, Nevada, Utah, Alaska, American Samoa, Hawaii, Idaho, Oregon,
Washington

District 50, Chicago, IL
(630) 620-7474

Responsible for Illinois, Indiana, Ohio

District 40, Dallas, TX
(214) 767-9116

Responsible for Texas

District 25, Des Moines, IA
(515) 727-8960

Responsible for Iowa, Nebraska

District 90, Jackson, MS
(601) 965-4312

Responsible for Alabama, Mississippi, Tennessee

District 30, Lawrence, KS
(785) 841-5600

Responsible for Kansas, Missouri

District 45, Madison, WI
(608) 240-4080

Responsible for Michigan, Wisconsin

District 20, Minneapolis, MN
(612) 370-2400

Responsible for Minnesota, Montana, North Dakota, South Dakota, Wyoming

District 60, Philadelphia, PA
(215) 597-4219

Responsible for Pennsylvania, New Jersey

District 80, Raleigh, NC
(919) 844-8400

Responsible for North Carolina, South Carolina, Kentucky

District 35, Springdale, AR
(479) 751-8412

Responsible for Arkansas, Louisiana, Oklahoma