Free 2359i - Federal

DEPARTMENT OF HEALTH AND HUMAN SERVICES FOOD AND DRUG ADMINISTRATION
1. NAME OF SHIPPER

INTERSTATE MILK SHIPPER's REPORT
(Submit an original and two (2) copies to the FDA Regional Office)
2. CITY 3. STATE

3-A. COUNTRY

4. STREET

5.

PLANT or BTU #

6.

PRODUCT CODE #s

7. SURVEY DATA
DAIRY FARMS TYPE OF RATING AREA RATING (%) DATE OF RATING TOTAL NUMBER APPENDIX N IS THE SHIPPER IN COMPLIANCE WITH THE PROVISIONS OF APPENDIX N? YES CERTIFIED STATE RATING OFFICER OFFICER'S CERTIFICATION EXPIRATION DATE NO INDIVIDUAL RECEIVING OR TRANSFER STATION MILK PLANT
1

ENFORCEMENT

NUMBER INSPECTED VOLUME RECEIVED DAILY (Cwt) RATING AGENCY SHD SDA OTHER AGENCY PROVIDING CONTINUOUS SUPERVISION OF SUPPLY

EARLIEST RATING DATE MONTH DAY YEAR

EXPIRATION RATING DATE 2 MONTH DAY YEAR

8. LABORATORY CONTROL
APPROVED LABORATORY NUMBER A. B. EXPIRATION DATE A. SPC B. A. B. DATE OF LAST TWO (2) SPLIT SAMPLES A. A. B. B. A. B. A. B. A. B. COLI PHOS RBC PROCESSED MILK TESTS APPROVED RAW MILK TESTS APPROVED DRUG RESIDUE TESTS A. B.

DRUG RESIDUE VIABLE SOMATIC TESTS COUNTS CELL COUNTS A. B. A. B. A. B.

APPROVED WATER LABORATORY AND DATE

WATER TESTS APPROVED

9. PUBLICATION (Written permission from a shipper must 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 STATE AGENCY
DATE OF REPORT SUBMITTED BY (Signature and Title)

FOR FDA REGIONAL OFFICE USE ONLY

Written permission from shipper dated
DATE SIGNATURE (FDA Milk Specialist)

on file and publication of rating/listing recommended.

1

Submit separate Form for each milk plant.

2

Expiration rating date is two (2) years after the earliest rating date, i.e., earliest rating date is 10/1/2008 with a corresponding expiration rating date of 9/30/2010, except if the Enforcement Rating is <90, than the expiration rating date is six (6) months after the earliest rating date, i.e., earliest rating date is 10/1/2008 with a corresponding expiration rating date of 3/31/2009.
PSC Graphics (301) 443-1090

FORM FDA 2359i (10/08) FRONT

(PREVIOUS EDITIONS ARE OBSOLETE)

EF

11. MILK PLANTS : List below the Name and Address of all shippers of raw milk and milk products received during the thirty (30) days preceding the earliest rating date of the Rating; Sanitation Compliance Rating; and Date of Rating. Plants receiving milk from an unlisted source(s), or source(s) with a Sanitation Compliance Rating below ninety (90), are not eligible for listing in the electronic publication, IMS LIST ­ SANITATION COMPLIANCE AND ENFORCEMENT RATINGS OF INTERSTATE MILK SHIPPERS. NAME OF SHIPPER (Include BTU or Plant #) CITY AND STATE SANITATION COMPLIANCE RATING DATE OF RATING

INSTRUCTIONS: Completed Forms must be received by the Milk Safety Team (HFS-316) to be included in the IMS List. Additional explanation is offered for the following Items: Item 1 : Name of Shipper ­ Limit shipper's name to not more than thirty-four (34) characters and spaces. If a receiving or transfer station is to be listed, please include "Receiving Station" or "Transfer Station" or "(RS)" or "(TS)" with the name of the shipper. Suggested abbreviations are published in the IMS List. Item 5 : Plant or BTU # ­ When the IMS Number is less than five (5) digits, leave the left-hand square(s) blank. Item 6 : Product Code #'s ­ Enter Product Code #s starting in the first (left-hand) space. Product Code #s are listed below: PRODUCT CODES: 1. Raw Milk for Pasteurization (May Include Lowfat, Skim or Cream) 2. Pasteurized Milk, Reduced Fat, Lowfat, or Skim 3. Heat-Treated (May Include Reduced Fat, Lowfat, Skim or Cream) 4. Pasteurized Half & Half, Coffee Cream, Creams 5. Ultra-Pasteurized (UP) Milk and Milk Products 6. Aseptic Milk and Milk Products (Including Flavored) 7. Cottage Cheese (Including Lowfat, Nonfat or Dry Curd) 8. Cultured or Acidified Milk and Milk Products 9. Yogurt (Including Lowfat or Skim) 10. Sour Cream Products (Acidified or Cultured) 11. Whey (Liquid) 12. Whey (Condensed) 13. Whey (Dry) 14. Modified Whey Products (Condensed or Dry) 15. Condensed Milk and Milk Products 16. Nonfat Dry Milk 17. Buttermilk (Condensed or Dry) 18. Eggnog 19. Lactose Reduced Milk and Milk Products 20. Low-Sodium Milk and Milk Products 21. Milk and Milk Products with Added Safe and Suitable Microbial Organisms (Such as Lactobacillus acidophilus) 22. Dry Milk and Milk Products 23. Anhydrous Milk Fat 24. Cholesterol Modified Anhydrous Milk Fat 25. Cholesterol Modified Fluid Milk Products 26. Cream (Condensed or Dry) 27. Blended Dry Products 28. Whey Cream 29. Whey Cream and Cream Blends 30. Grade "A" Lactose 31. Raw Goat Milk for Pasteurization 32. Pasteurized Goat Milk and Milk Products 33. Cultured Goat Milk and Milk Products 34. Condensed or Dry Goat Milk and Milk Products 35. Ultra-Pasteurized (UP) Goat Milk and Milk Products 36. Aseptic Goat Milk and Milk Products 37. Raw Sheep Milk for Pasteurization 38. Cultured Sheep Milk and Milk Products 39. Concentrated Raw Milk Products for Pasteurization 40. Concentrated Pasteurized Milk Products 41. Ultra-Filtered (UF) Permeate from Milk 42. Ultra-Filtered (UF) Permeate from Whey

FORM FDA 2359i (10/08) BACK

(PREVIOUS EDITIONS ARE OBSOLETE)