Hours of Operation

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information. To submit electronically, complete the electronically-fillable form and save the form on your hard drive. Print the form and sign it. Scan the form and e-mail the completed form to
the Grant Curator in the appropriate FSIS District Office. For paper copies, send the signed application form to the Grant Curator at the District Office mailing address.

2. DATE:

1. ESTABLISHMENT NO.:

U. S. DEPARTMENT OF AGRICULTURE
FOOD SAFETY AND INSPECTION SERVICE

HOURS OF OPERATION
REQUEST/APPROVAL

3. DISTRICT OFFICE NAME AND MAILING ADDRESS:

4. ESTABLISHMENT NAME, MAILING ADDRESS, AND E-MAIL ADDRESS:

5. PHYSICAL LOCATION OF ESTABLISHMENT:

6. TYPES OF INSPECTION: (check all that apply)
MEAT

POULTRY

IMPORT

EGG PRODUCTS

SILURIFORMES - FISH

SCHEDULE OF OPERATIONS
SECOND SHIFT

FIRST SHIFT
DAYS

START TIME

LUNCH

END TIME

DAYS

START TIME

SUN.

SUN.

MON.

MON.

TUES.

TUES.

WED.

WED.

THURS.

THURS.

FRI.

FRI.

SAT.

SAT.
EXEMPT ACTIVITIES

CUSTOM SLAUGHTER
(livestock only)
YES

NO

END TIME

JURISDICTION

CUSTOM EXEMPT PROCESSING
(livestock only)
YES

LUNCH

NO

RETAIL EXEMPT
YES

NO

DUAL JURISDICTION ESTABLISHMENT
with FDA
YES

NO

COMMENTS:

DATE:

PRINTED NAME
OF APPLICANT:
SIGNATURE
OF APPLICANT:

FSIS USE ONLY
FRONTLINE SUPERVISOR:

RECOMMENDED

NOT RECOMMENDED

COMMENTS:

DATE:

PRINTED NAME OF
FRONTLINE SUPERVISOR:
SIGNATURE OF
FRONTLINE SUPERVISOR:

DISTRICT MANAGER USE
DISTRICT MANAGER:

APPROVED

NOT APPROVED

The assigned inspector's tour of duty for your establishment is ______________________________________________________________________________________ .
Should you request overtime or holiday inspection service outside of the assigned inspector's tour of duty, if granted, you shall reimburse FSIS in accordance with 9 CFR
307.5(a) or 9 CFR 381.38.
DISTRICT MANAGER
SIGNATURE:
FSIS FORM 5200-15 (03/29/2017)

DATE: