Form 04-573 - Alaska Seafood Processor And Exporter 1998 License And Permit Application Intent To Operate Page 7

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Alaska Seafood Processor and Exporter
SCHEDULE D
1998 ADEC Permit Application
Name
Federal EIN
ADEC Permit or Shellfish Number
SCHEDULE D - ADEC INFORMATION
ADEC Contact
Riki Lebman (907) 269-7637 Fax (907) 269-7510
This page must be completed by all new applicants and only those processors indicated by the last three numbers in their permit for the year
shown below:
AK #s from 000-300 submit complete application in years ending in 7, 0, and 3
AK #s from 301-600 submit complete application in years ending in 8, 1, and 4
AK #s from 601-999 submit complete application in years ending in 9, 2, and 5
AK #s over 1000 use the last 3 digits to determine which year to submit a complete application
Renewals do not need to complete this form except during the above years
(approximately every 3 years)
PRODUCT DETAIL
(Complete the following information)
Refer to Page 1 for species and packaging types
List Days of Anticipated Processing
Max. Production
Packaging Type to
Packaging Size
Example of Date
Raw Seafood
Process Type
Possible Per Day
be Used for
for Each Finish
code Used on
Product/Specie
Raw Product
(tons or lbs)
Finished Product
Product
Label
INGREDIENTS AND ADDITIVE INFORMATION
(List ingredients and additives used for each product above)
Brining ingredients
Formulation ingredients
Additives
Y
Y
Source of ice
Permitted Source?
Yes
No
(if not produced on the premises)
HACCP INFORMATION
Y
Y
Has a hazard analysis been conducted for each finished product?
Yes
No
Identify which products a HACCP plan has been written for:
FOOD SERVICE (Check those that apply)
Contact: Larry Montgomery (907) 269-7629
Y
Y
Food service provided?
Yes
No
If yes, for how many?
Y
Y
Food service permit number
Check if:
Previously issued
New
WATER (Complete information below that is applicable to each drinking, processing, or cooling system)
Contact: Susan Randlett (907) 269-3075
Water Type
ID# or Source
Gallons/day
Disinfectant
PPM
Method (circle one)
ID#
Injection
Public Water System
Batch
Source
Injection
Other Fresh Water
Batch
Injection
Salt Water
Not Applicable
Batch
Form 04-573 (Rev. 9/97)
Page 7

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