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pdfHandler Name:
Plant Location:
Order on which plant was pooled:
Completed by:
32
November 20xx
Volume in Pounds by Container Size
Plastic Containers*
(Type of Product)
Conventional Pasteurized Milk-HTST
Phone Number:
Gal (128 OZ)
1/2 Gal (64 OZ)
Quart (32 OZ)
Pint ( 16 OZ)
14 OZ
12 OZ
10 OZ
1/2 Pint (8 OZ)
Other sizes
Total
Whole milk
0
2% Reduced fat
0
1% Low fat
0
Fat free skim
0
Buttermilk
0
Eggnog
0
Whole milk
0
2% Reduced fat
0
1% Low fat
0
Fat free skim
0
Extended Shelf Life Pasteurized Milk - NON ORGANIC
Whole milk
0
(including ultra pasteurizaton or aseptic pasteurization)
2% Reduced fat
0
1% Low fat
0
Fat free skim
0
Buttermilk
0
Eggnog
0
Whole milk
0
2% Reduced fat
0
1% Low fat
0
Fat free skim
0
Organic Milk - (Standard pasteurization
Whole milk
0
or extended shelf life pasteurization)
2% Reduced fat
0
1% Low fat
0
Fat free skim
0
Buttermilk
0
Eggnog
0
Whole milk
0
2% Reduced fat
0
1% Low fat
0
Fat free skim
0
Flavored Standard Pasteurized Milk
Flavored Non-Organic Extended Shelf Life
Flavored Organic Milk
* Include rigid blow mold or thermoformed plastic, single-serve round containers, plastic-lined boxes, and plastic bags sold separately.
Handler Name:
Plant Location:
0
0
November 20xx
Volume in Pounds by Container Size
Paper Containers*
(Type of Product)
1/2 Gal (64 OZ)
Quart (32 OZ)
Pint ( 16 OZ)
1/2 Pint (8 OZ)
Other sizes
Total
Conventional Pasteurized Milk-HTST
Whole milk
2% Reduced fat
1% Low fat
Fat free skim
Buttermilk
Eggnog
0
0
0
0
0
0
Flavored Standard Pasteurized Milk
Whole milk
2% Reduced fat
1% Low fat
Fat free skim
0
0
0
0
Extended Shelf Life Pasteurized Milk - NON ORGANIC
(including ultra pasteurizaton or aseptic pasteurization)
Whole milk
2% Reduced fat
1% Low fat
Fat free skim
Buttermilk
Eggnog
0
0
0
0
0
0
Flavored Non-Organic Extended Shelf Life
Whole milk
2% Reduced fat
1% Low fat
Fat free skim
0
0
0
0
Organic Milk - (Standard pasteurization
or extended shelf life pasteurization)
Whole milk
2% Reduced fat
1% Low fat
Fat free skim
Buttermilk
Eggnog
0
0
0
0
0
0
Flavored Organic Milk
Whole milk
2% Reduced fat
1% Low fat
Fat free skim
0
0
0
0
* Include wax-coated or plastic-coated paper containers including foil-lined UHT paper containers.
Handler Name:
Plant Location:
0
0
November 20xx
Volume in Pounds by Container Size
Glass Containers
(Type of Product)
1/2 Gal (64 OZ)
Quart (32 OZ)
Pint ( 16 OZ)
1/2 Pint (8 OZ)
Other sizes
Total
Conventional Pasteurized Milk-HTST
Whole milk
2% Reduced fat
1% Low fat
Fat free skim
Buttermilk
Eggnog
0
0
0
0
0
0
Flavored Standard Pasteurized Milk
Whole milk
2% Reduced fat
1% Low fat
Fat free skim
0
0
0
0
Extended Shelf Life Pasteurized Milk - NON ORGANIC
(including ultra pasteurizaton or aseptic pasteurization)
Whole milk
2% Reduced fat
1% Low fat
Fat free skim
Buttermilk
Eggnog
0
0
0
0
0
0
Flavored Non-Organic Extended Shelf Life
Whole milk
2% Reduced fat
1% Low fat
Fat free skim
0
0
0
0
Organic Milk - (Standard pasteurization
or extended shelf life pasteurization)
Whole milk
2% Reduced fat
1% Low fat
Fat free skim
Buttermilk
Eggnog
0
0
0
0
0
0
Flavored Organic Milk
Whole milk
2% Reduced fat
1% Low fat
Fat free skim
0
0
0
0
Handler Name:
0
Plant Location:
0
November 20xx
Volume of Milk Shipped to Various Distribution Channels - Of the following methods of distribution,
please report the volume of sales within each channel
Volume in Pounds
Supermarket chains
Mass merchandisers (Walmart, Target, etc.)
Club Stores (Costco, Sam's Club, BJs Wholesale, etc)
Convenience stores (gas stations, neighborhood stores)
Drug Stores (CVS,Rite Aid, Walgreen, etc.)
Schools (secondary and or colleges)
Institutional (hospitals, military, nursing homes, prisons)
Wholesale distributors
Home delivery routes
Internet Ordered Home Delivery
Other
Total
0
Handler Name:
Plant Location:
0
0
November 20xx
Volume in Pounds
Totals by Container Type
(Type of Product)
Plastic
Paper
Glass
Total
Conventional Pasteurized Milk-HTST
Whole milk
2% Reduced fat
1% Low fat
Fat free skim
Buttermilk
Eggnog
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Flavored Standard Pasteurized Milk
Whole milk
2% Reduced fat
1% Low fat
Fat free skim
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Extended Shelf Life Pasteurized Milk - NON ORGANIC
(including ultra pasteurizaton or aseptic pasteurization)
Whole milk
2% Reduced fat
1% Low fat
Fat free skim
Buttermilk
Eggnog
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Flavored Non-Organic Extended Shelf Life
Whole milk
2% Reduced fat
1% Low fat
Fat free skim
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Organic Milk - (Standard pasteurization
or extended shelf life pasteurization)
Whole milk
2% Reduced fat
1% Low fat
Fat free skim
Buttermilk
Eggnog
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Flavored Organic Milk
Whole milk
2% Reduced fat
1% Low fat
Fat free skim
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Grand Total Pounds
0
Form Approved
OMB 0581-0032
Exp. XX/XXXX
This report is required by the Order in accordance with 7 U.S.C. 608 C & D. Failure to report can result in the assessment of a
civil penalty of up to $1,000 per day (7 U.S.C. 608c(14)(B) or, upon conviction, in a fine of up to $5,000 per day (7 U.S.C. 608c
(14)(B).
Paperwork Reduction Act of 1995 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 0581-0032. The time required to complete this information collection is
estimated to average 3 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.
USDA Civil Rights Statement In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights
regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA
programs are prohibited from discriminating based on race, color, national origin, religion, sex, gender identity (including gender
expression), sexual orientation, disability, age, marital status, family/parental status, income derived from a public assistance
program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by
USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by program or incident.
Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print,
audiotape, American Sign Language, etc.) should contact the responsible Agency or USDA’s TARGET Center at (202) 7202600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information
may be made available in languages other than English.
To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online
at http://www.ascr.usda.gov/complaint_filing_cust.html and at any USDA office or write a letter addressed to USDA and provide
in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit
your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil
Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email:
[email protected].
USDA is an equal opportunity provider, employer, and lender.
File Type | application/pdf |
Author | pfredericks |
File Modified | 2020-02-07 |
File Created | 2020-01-20 |