Free FDA 2359h - Federal

DEPARTMENT OF HEALTH AND HUMAN SERVICES PUBLIC HEALTH SERVICE FOOD AND DRUG ADMINISTRATION

INTERSTATE MILK SHIPPER's CHECK RATING REPORT
NAME AND ADDRESS OF SHIPPER

TO

The Procedures Governing the Cooperative State - Public Health Service/Food and Drug Administration Program of the National Conference on Interstate Milk Shipments specifies that the PHS/FDA shall conduct check ratings or HACCP audits, if applicable, of the sanitation compliance status of listed interstate milk shippers to assure the validity of published listings. A check rating or HACCP audit, if applicable, of the above identified shipper has disclosed the following information.

LISTED RATING/AUDIT

CHECK RATING/AUDIT

TOTAL NUMBER

DATE PRODUCERS RECEIVING STATION TRANSFER STATION PLANT

TYPE OF PRODUCER RATING PRODUCERS RECEIVING STATION TRANSFER STATION PLANT ENFORCEMENT RATING

LISTED RATING/AUDIT AREA INDIVIDUAL

CHECK RATING/AUDIT AREA INDIVIDUAL

NO. INSPECTED

PRODUCERS RECEIVING STATION TRANSFER STATION PLANT
APPENDIX N IS THIS SHIPPER IN COMPLIANCE WITH THE PROVISIONS OF APPENDIX N? YES NO

PRODUCERS ­ NUMBER VIOLATING
1 SCC

NUMBER OF DEBITS ­ ITEMS OF SANITATION
15ABC 19GH 19CD 15DE 18AB 19AB 19EF 18C BACTI/ DRUGS
EF

8-2

8-5

2C

2D

5C

5D

2A

2B

2E

5A

5B

5E

10

11

12

13

14

16

MILK PLANT, RECEIVING STATION OR TRANSFER STATION ­ NUMBER VIOLATING (Including Partial Debits)
15a.ABC 15b.ABC 12CDEF 16ABC1 16ABC2 16BC3 BACTI BACTI 18/19 12AB COLI 16D 16E

4A

4B

10

11

13

14

17

20

21

CONDENSED AND/OR DRY MILK PLANT ­ NUMBER VIOLATING (Including Partial Debits)
15a.ABC 15b.ABC 12CDEF 16ABC1 16ABC2 16BC3 18/19 12AB COLI 16D 16E

4A

4B

10

11

13

14

17

20

21

1. A receiving station shall comply with Items 1p-15p, inclusive, and 17p, 20p, and 22p, except that the partitioning requirements of Item 5p shall not apply. 2. A transfer station shall comply with Items 1p, 4p, 6p-15p, inclusive, 20p, 22p and as climatic and operating conditions require, the applicable provisions of Items 2p and 3p; provided in every case, overhead protection shall be provided.

The results of this check rating or HACCP audit, if applicable, conducted by PHS/FDA indicate that the following action is necessary to comply with the NCIMS Agreements. Failure to submit a new rating or reinspection data to the FDA Regional Office within five (5) working days of the due date will result in the automatic withdrawal of certification from the IMS List. No Action Necessary Reinspection by (date)
RECEIVED BY (Signature of State Official)

New Rating by (date) Immediate Withdrawal of Certification
TITLE OF STATE OFFICIAL DATE

FDA MILK SPECIALIST

FORM FDA 2359h (10/08) Previous Edition is Obsolete

Part 1. HQ's Copy

Part 2. Region

Part 3. State

Part 4. Optional Use
PSC Graphics (301) 443-1090

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