FOR FDA USE ONLY
REPORT OF CERTIFICATION
DEPARTMENT OF HEALTH AND HUMAN SERVICES
1
2
3
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5
(Fabrication of Single-Service Containers and/or
FOOD AND DRUG ADMINISTRATION
Closures for Milk and/or Milk Products)
IDENTIFICATION
1. NAME OF SINGLE-SERVICE FABRICATING PLANT
2. CITY
3. STATE/COUNTRY
4. STREET
6.
CODE
5.
MFG. CODE NO.
PRODUCT
MATERIAL
7. AGENCY OR SSC, AS APPLICABLE, PROVIDING ROUTINE INSPECTION
56
57
58
59
60
61
62
PRODUCT CODE (60)
MATERIAL CODE (62)
1. Containers
1. Metal
2. Closures
2. Paper (Includes laminates)
3. Plastic
3. Other products
4. Metal and paper
4. Containers and closures
7.a. RATING/CERTIFICATION
7.b. DATE OF PLANT
7.d. EXPIRATION DATE *
5. Metal and plastic
5. Containers and other
CERTIFICATION
PERSONNEL
MONTH
DAY
YEAR
products
6. Paper and plastic
SHD
Other
6. Closures and other
7. Metal, paper and plastic
67
68
69
70
71
72
products
8. Glass
SDA
TPC
7.c. SANITATION
20
7. Containers, closures and
9. Rubber
COMPLIANCE RATING
SDL
SSC
10. Paper, metal, plastic and glass
other products
11. Ceramic
8. SRO OR SSC
*EXPIRATION DATE
Certification of single-service manufacturing plants may be valid for a period not to exceed
one (1) or two (2) years from the earliest certification date. The expiration date is one (1) or
9. CERTIFICATION RECOMMENDED
9.a. LISTING TYPE
two (2) years from the earliest certification date. NOTE: Certifications conducted by SSCs
shall only be valid for a period not to exceed one (1) year from the earliest certification date.
YES
NO
FULL
PARTIAL
LABORATORY CONTROL
10. NAME AND ADDRESS (OR CODE) OF APPROVED LABORATORY
11. INSPECTION RESULTS (Place an "X" under Items debited)
1
2
3
4
5
6
7
8
9
10
11
12
13
13
14
15
16
16
17
18
19
20
20
21
17
a,b,c,
d,e,
a
b,c
a,b
a,b,f
c,d,e
c
f,g,i,k
h,j
d,e
12. PERMISSION TO PUBLISH
Permission is hereby granted to release and publish the above stated certification for use by Regulatory/Rating
Agencies and prospective purchasers.
It is understood and agreed by the undersigned that the official Rating Agency or SSC, as applicable, may
review and appraise the single-service fabricating plant at any time during the period of time the above
certification is in effect. It is further understood that failure to maintain the above certification will subject this
plant to withdrawal from the IMS Listing. We will notify the Rating Agency or SSC, as applicable, of any
significant changes made in the operation of this plant.
12.a. NAME OF PLANT
12.b. OFFICER AUTHORIZING RELEASE
12.c. TITLE
13. SUBMISSION OF REPORT BY MILK SANITATION RATING AGENCY OR SSC, AS APPLICABLE
13.a. DATE OF REPORT
13.b. RECOMMENDED CLASSIFICATION
13.c. SUBMITTED BY (Signature and Title)
ACCEPTED
YES
NO
FOR FDA USE ONLY
14. DATE RECEIVED
15. PUBLICATION OF RATING RECOMMENDED
YES
NO
(If "NO", indicate why.)
16. DATE TRANSMITTED
17. SIGNATURE (FDA Regional Milk Specialist)
FORM FDA 2359d (11/15)
EF
PSC Publishing Services: (301) 443-6740
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