Free 2399b - Federal

DEPARTMENT OF HEALTH AND HUMAN SERVICES FOOD AND DRUG ADMINISTRATION

TANKER SERIAL NO. TANKER PERMIT NO. STATE ISSUING PERMIT

MILK TANK TRUCK INSPECTION REPORT
MILK TANK TRUCK OWNER ADDRESS OF OWNER

SAMPLER'S PERMIT NO. DRIVER DELIVERS TO

NAME OF OPERATOR / DRIVER ADDRESS OF DRIVER

NAME AND ADDRESS OF INSPECTION LOCATION

An inspection of your milk tank truck showed violations existing in the Items checked below in the non-compliance column. You are further notified that this inspection report serves as notification of the intent to suspend this milk tank truck's permit if the violations are not in compliance at the time of the next inspection. (Refer to Sections 3 and 5 of the Grade "A" Pasteurized Milk Ordinance.)
NonCom- Com- N/A pliance pliance NonCom- Com- N/A pliance pliance

1. SAMPLES AND SAMPLING EQUIPMENT (PMO, Appendix B)
a. Storage of Sample Containers b. Sample Box in Good Repair; Clean c. Sample Transfer Instrument d. Sampling Transfer Instrument Container e. Sample Storage f. Sample Storage Compartments g. Samples 0°C - 4.4°C (32°F - 40°F), Temperature Control h. Approved Thermometer Available

4. EXTERIOR CONDITION OF TANK
(PMO, Appendix B)

5. CLEANING/ SANITIZING RECORD (PMO, Section 7, Item 12p)
a. Is Recording Chart Available? b. Is Cleaning /Sanitizing Tag Available? 1. Recording Chart Available for CrossReference? 2. Attached to Tanker? 3. Date of Last Cleaning /Sanitizing (PMO, Appendix B) 4. Properly Completed (PMO, Appendix B)

2. PRODUCT TEMPERATURE 7°C (45°F) OR LESS
(PMO, Section 7, Items 18r and 17p) a. Temperature of Product in Tank b. Product in External Fluid Transfer Systems that Exceeds 7°C (45°F) is Discarded

6. LOCATION OF LAST CLEANING/SANITIZING

7. LABELING 8. VEHICLE AND MILK TANK TRUCK PROPERLY IDENTIFIED 9. PREVIOUS INSPECTION SHEET OR AFFIXED LABEL AVAILABLE 10. SAMPLE CHAIN-OF-CUSTODY
REMARKS (If additional space is required, please place information on the back of this Form or on a separate page.)

3. EQUIPMENT CONSTRUCTION, CLEANING, SANITIZING AND REPAIR (PMO, Section 7, Items 10p, 11p and 12p)
a. Dome Lid Assembly b. Gasket(s) c. Vent(s) d. Pump(s) e. Hose(s) f. Hose Connection(s) g. Hose(s) more than 8 Ft in Length Mechanically Cleaned h. Valve(s) i. Protection from Contamination j. Interior Condition of Tank k. Aseptic Sampler l. Other (Specify) FORM FDA 2399b (10/08) FRONT

SANITARIAN AGENCY (PREVIOUS EDITIONS ARE OBSOLETE)

DATE

PSC Graphics (301) 443-1090

EF

MILK TANK TRUCK INSPECTION REPORT
REMARKS (Continued)

FORM FDA 2399b (10/08)

BACK

(PREVIOUS EDITIONS ARE OBSOLETE)