Free FD-2359d - Federal

DEPARTMENT OF HEALTH AND HUMAN SERVICES FOOD AND DRUG ADMINISTRATION

(Fabrication of Single-Service Containers and Closures for Milk and Milk Products)
IDENTIFICATION
2. CITY

REPORT OF CERTIFICATION

FOR FDA USE ONLY
1 2 3 4 5

1. NAME OF SINGLE-SERVICE FABRICATING PLANT 4. STREET 7. AGENCY PROVIDING ROUTINE INSPECTION

3. STATE 6.
59 60

5.
56

MFG. CODE NO.
57 58

CODE
MATERIAL

PRODUCT

61

62

7.a.

RATING AGENCY
SHD SDA SDL Other

7.b.

DATE OF INSPECTION

*EXPIRATION DATE

PRODUCT CODE (60) 1. Containers 2. Closures 3. Other products 4. Containers and closures 7.c. EXPIRATION DATE * 5. Containers and other MONTH DAY YEAR products 6. Closures and other 67 68 69 70 71 72 products 7. Containers, closures and other products 8. SANITARIAN OR CONSULTANT

20

MATERIAL CODE (62) 1. Metal 2. Paper (Includes laminates) 3. Plastic 4. Metal and paper 5. Metal and plastic 6. Paper and plastic 7. Metal, paper and plastic 8. Glass 9. Rubber 10. Paper, metal, plastic and glass

This date is 15 or 24 months following the certification date. Certification of singleservice manufacturing plants may be valid for 1 or 2 years. In the case of a 1 year certification, a 90 day grace period is included to provide time for the transmission of the completed Report of Certification (Form FDA 2359d).

9. CERTIFICATION RECOMMENDED YES NO

9a. LISTING TYPE FULL PARTIAL

10. NAME AND ADDRESS (OR CODE) OF APPROVED LABORATORY

LABORATORY CONTROL

11. INSPECTION RESULTS (Place an "X" under Items involved)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21

12. PERMISSION TO PUBLISH

Permission is hereby granted to release and publish the above stated certification for use by State and local milk control authorities and prospective purchasers. It is understood and agreed by the undersigned that the official Rating Agency 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 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 STATE MILK SANITATION RATING AGENCY 13.c. SUBMITTED BY (Signature and Title) YES 14. DATE RECEIVED NO NO (If "NO", indicate why.)

13.a. DATE OF REPORT

13.b. RECOMMENDED CLASSIFICATION ACCEPTED

FOR FDA USE ONLY 15. PUBLICATION OF RATING RECOMMENDED YES

16. DATE TRANSMITTED

17. SIGNATURE (FDA Regional Milk Specialist)

FORM FDA 2359d (10/08)

PSC Graphics: (301) 443-1090

EF