Interstate Milk Shipper'S Report
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23-A. COUNTRY
INTERSTATE MILK SHIPPER’s REPORT
DEPARTMENT OF HEALTH AND HUMAN SERVICES
(Submit an original and two (2)
FOOD AND DRUG ADMINISTRATION
copies to the FDA Regional Office)
1. NAME OF SHIPPER
2. CITY
3. STATE
4. STREET
5.
PLANT or BTU #
6.
PRODUCT CODE #s
7. SURVEY DATA
DAIRY FARMS
RECEIVING OR
1
MILK PLANT
ENFORCEMENT
TYPE OF RATING
TRANSFER STATION
AREA
INDIVIDUAL
RATING (%)
DATE OF RATING
APPENDIX N
TOTAL NUMBER
IS THE SHIPPER IN COMPLIANCE WITH THE
NUMBER INSPECTED
PROVISIONS OF APPENDIX N?
YES
NO
VOLUME RECEIVED
DAILY (Cwt)
RATING AGENCY
CERTIFIED RATING OFFICER
OFFICER'S CERTIFICATION
EARLIEST RATING DATE
EXPIRATION DATE
SDL
SHD
MONTH
DAY
YEAR
SDA
TPC
OTHER
AGENCY PROVIDING CONTINUOUS SUPERVISION OF SUPPLY
2
EXPIRATION RATING DATE
MONTH
DAY
YEAR
8. LABORATORY CONTROL
APPROVED LABORATORY NUMBER
EXPIRATION DATE
PROCESSED MILK TESTS APPROVED
RAW MILK TESTS APPROVED
A.
A.
DRUG RESIDUE
VIABLE
SOMATIC
DRUG RESIDUE
SPC
COLI
PHOS
RBC
TESTS
COUNTS
CELL COUNTS
TESTS
B.
B.
A.
A.
A.
A.
A.
A.
A.
A.
B.
B.
B.
B.
B.
B.
B.
B.
DATE OF LAST TWO (2) SPLIT SAMPLES
APPROVED WATER LABORATORY AND DATE
WATER TESTS APPROVED
A.
A.
B.
B.
9. PUBLICATION (Written permission from a shipper shall be filed at a Regional Office of FDA prior to the publication of rating/listing.)
LETTER OF PERMISSION TO PUBLISH IS TRANSMITTED WITH THIS REPORT?
YES
NO
10. SUBMISSION OF REPORT BY RATING AGENCY
SUBMITTED BY (Signature and Title)
DATE OF REPORT
FOR FDA REGIONAL OFFICE USE ONLY
Written permission from shipper dated
on file and publication of rating/listing recommended.
SIGNATURE (FDA Milk Specialist)
DATE
1
2
Submit separate Form for each milk plant.
The expiration rating date is two (2) years after the earliest rating date, i.e., earliest rating date is 10/1/2013 with a corresponding
expiration rating date of 9/30/2015, except if the Enforcement Rating is <90, then the expiration rating date is six (6) months
after the earliest rating date, i.e., earliest rating date is 10/1/2013 with a corresponding expiration rating date of 3/31/2014.
EF
FORM FDA 2359i (10/13) FRONT
(PREVIOUS EDITIONS ARE OBSOLETE)
PSC Publishing Services (301) 443-6740
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