Form M-8 - Renewal Application To Operate A Bulk Tank Unit / Milk Plant
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1New Jersey Department of Health
FOR STATE USE ONLY
Consumer, Environmental and Occupational Health Service
Check/Money Order No.:
PO Box 369
Trenton, NJ 08625-0369
Check/MO Date:
Phone: 609-826-4935
Amount:
RENEWAL APPLICATION TO OPERATE A
Logger Initials:
BULK TANK UNIT / MILK PLANT
PURSUANT TO N.J.S.A. 24:10-57.2
June 30,
FOR THE PERIOD ENDING:
LOCATED AT:
Failure to apply for renewal may subject you to penalty as provided by law. Expiration date appears on license.
Please provide all information requested. If you have discontinued operations, complete last section only and
return to above address. TYPE OR PRINT WITH BALL POINT PEN.
If Name or Address is incorrect, make necessary corrections below.
REASONS FOR CORRECTIONS:
Change in Trade Name
Change in Corporate Structure
Change in Location
Change in Mailing Address
Change in Ownership
Fax Number:
Email Address:
Federal ID #/SSN:
MAKE CHECK OR MONEY ORDER PAYABLE TO: “TREASURER, STATE OF NEW JERSEY.”
FEE SCHEDULE
ANNUAL FEE
0 – 25 Dairy Farms.............................................................$50.00
Over 25 Dairy Farms........................................................$100.00
______________
1. Total number of Dairy Farms supplying milk directly to this plant?
2. Name and address of each milk and bulk milk hauler from whom milk and milk products are received.
I certify that the above information is correct.
CORPORATE OFFICER INFORMATION
Name of President (Print)
Name of Secretary (Print)
Name of Vice-President (Print)
Name of Treasurer (Print)
AFFIDAVIT
State of ____________________________
County of ___________________________
I, ____________________________________________, being duly sworn according to law upon his(her) oath deposes and
says that he(she) is (President, Vice President, Secretary, Treasurer, Owner) and hereby certifies that the information given in
this application is true and complete to the best of his(her) knowledge, information and belief.
Sworn and Subscribed before me this ____________ day
___________________________________________
Signature and Title of Applicant
of _______________________, in the year ___________.
______________________________________________
_______________________________
Notary Public Signature
Date
DISCONTINUANCE OF OPERATIONS INFORMATION
Date Operations Discontinued
Name of Purchaser
Date Sold
Address of Purchaser
Signature of Former Operator
Address of Former Operator
M-8
JAN 13
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