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DEPARTMENT OF HEALTH AND HUMAN SERVICES FOOD AND DRUG ADMINISTRATION
(See Reverse of Part III for Instructions)

(Check One)

Certification Cancellation

Change Renewal

Form Approved: OMB No. 0910-0021 Expiration Date: January 31, 2010 See Burden Statement on back of Part III.

1. SHELLFISH DEALER / SHIPPER (Name)

SECTION I - COMPLETED BY STATE SHELLFISH CONTROL AUTHORITY 2. CERTIFICATION
a) CERTIFICATE NUMBER b) DATE CERTIFIED

FACILITY ADDRESS (Include Street No., City, State, & ZIP)
c) STATE d) EXPIRATION DATE

MAILING ADDRESS (If different than above)

e) CATEGORY SYMBOL

DP - Depuration
TELEPHONE

RP - Repacker SS - Shell Stock Shipper

RS - Reshipper PHP - Post Harvest Processor

(

)

SP - Shucker-Packer

3. DATE OF ON-SITE INSPECTION

4. STATE SHELLFISH STANDARDIZATION INSPECTOR (Print Name) 7. REASON FOR CANCELLATION (Check One) Decertification Other (Please Specify)

5. EXPIRATION DATE OF INSPECTOR'S STANDARDIZATION

6. CANCELLATION DATE

Out of Business

8. a) STATE SHELLFISH CONTROL AUTHORITY DESIGNEE (Print Name)

b) SIGNATURE

c) DATE CERTIFICATE SENT TO FDA

SECTION II - COMPLETED BY DIVISION OF COOPERATIVE PROGRAMS - FDA
9. DATE CERTIFICATE RECEIVED 10. DATE CERTIFICATE PUBLISHED

THIS CERTIFICATE MUST BE KEPT ON FILE FOR A PERIOD OF TWO (2) YEARS.
FORM FDA 3038 (3/07)
(Replaces Forms FDA 3038b and FDA 3038c which are obsolete.)

PART 1 - HFS-625

INTERSTATE SHELLFISH DEALER'S CERTIFICATE
PSC Graphics: (301) 443-1090

EF

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DEPARTMENT OF HEALTH AND HUMAN SERVICES FOOD AND DRUG ADMINISTRATION
(See Reverse of Part III for Instructions)

(Check One)

Certification Cancellation

Change Renewal

Form Approved: OMB No. 0910-0021 Expiration Date: January 31, 2010 See Burden Statement on back of Part III.

1. SHELLFISH DEALER / SHIPPER (Name)

SECTION I - COMPLETED BY STATE SHELLFISH CONTROL AUTHORITY 2. CERTIFICATION
a) CERTIFICATE NUMBER b) DATE CERTIFIED

FACILITY ADDRESS (Include Street No., City, State, & ZIP)
c) STATE d) EXPIRATION DATE

MAILING ADDRESS (If different than above)

e) CATEGORY SYMBOL

DP - Depuration
TELEPHONE

RP - Repacker SS - Shell Stock Shipper

RS - Reshipper PHP - Post Harvest Processor

(

)

SP - Shucker-Packer

3. DATE OF ON-SITE INSPECTION

4. STATE SHELLFISH STANDARDIZATION INSPECTOR (Print Name) 7. REASON FOR CANCELLATION (Check One) Decertification Other (Please Specify)

5. EXPIRATION DATE OF INSPECTOR'S STANDARDIZATION

6. CANCELLATION DATE

Out of Business

8. a) STATE SHELLFISH CONTROL AUTHORITY DESIGNEE (Print Name)

b) SIGNATURE

c) DATE CERTIFICATE SENT TO FDA

SECTION II - COMPLETED BY DIVISION OF COOPERATIVE PROGRAMS - FDA
9. DATE CERTIFICATE RECEIVED 10. DATE CERTIFICATE PUBLISHED

THIS CERTIFICATE MUST BE KEPT ON FILE FOR A PERIOD OF TWO (2) YEARS.
FORM FDA 3038 (3/07)
(Replaces Forms FDA 3038b and FDA 3038c which are obsolete.)

PART 2 - REGIONAL SHELLFISH SPECIALIST

INTERSTATE SHELLFISH DEALER'S CERTIFICATE

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DEPARTMENT OF HEALTH AND HUMAN SERVICES FOOD AND DRUG ADMINISTRATION
(See Reverse of Part III for Instructions)

(Check One)

Certification Cancellation

Change Renewal

Form Approved: OMB No. 0910-0021 Expiration Date: January 31, 2010 See Burden Statement on back of Part III.

1. SHELLFISH DEALER / SHIPPER (Name)

SECTION I - COMPLETED BY STATE SHELLFISH CONTROL AUTHORITY 2. CERTIFICATION
a) CERTIFICATE NUMBER b) DATE CERTIFIED

FACILITY ADDRESS (Include Street No., City, State, & ZIP)
c) STATE d) EXPIRATION DATE

MAILING ADDRESS (If different than above)

e) CATEGORY SYMBOL

DP - Depuration
TELEPHONE

RP - Repacker SS - Shell Stock Shipper

RS - Reshipper PHP - Post Harvest Processor

(

)

SP - Shucker-Packer

3. DATE OF ON-SITE INSPECTION

4. STATE SHELLFISH STANDARDIZATION INSPECTOR (Print Name) 7. REASON FOR CANCELLATION (Check One) Decertification Other (Please Specify)

5. EXPIRATION DATE OF INSPECTOR'S STANDARDIZATION

6. CANCELLATION DATE

Out of Business

8. a) STATE SHELLFISH CONTROL AUTHORITY DESIGNEE (Print Name)

b) SIGNATURE

c) DATE CERTIFICATE SENT TO FDA

SECTION II - COMPLETED BY DIVISION OF COOPERATIVE PROGRAMS - FDA
9. DATE CERTIFICATE RECEIVED 10. DATE CERTIFICATE PUBLISHED

THIS CERTIFICATE MUST BE KEPT ON FILE FOR A PERIOD OF TWO (2) YEARS.
FORM FDA 3038 (3/07)
(Replaces Forms FDA 3038b and FDA 3038c which are obsolete.)

PART 3 - STATE REGULATORY AGENCY

INTERSTATE SHELLFISH DEALER'S CERTIFICATE

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Instructions for completing Form FDA 3038 (3/07) Section I - Completed by State Shellfish Certification Agency
1. Shellfish Dealer/Shipper: Name, Facility Address, Street No., City/Town, State, ZIP, and Telephone. Include mailing address if different than physical location of facility. 2. Certification: Certificate Number - a unique number assigned to each certified shellfish dealer; Date Certified; State - two letter State Code; Expiration Date - date certificate expires; Category Symbol - two or three letter code designating dealer process. 3. Date of On-Site Inspection: Date plant was inspected for certification. 4. State Shellfish Standardization Inspector: Print name of Inspector who conducted the on-site inspection. 5. Expiration Date of Inspector's Standardization: Print date the inspector's standardization will expire. 6. Cancellation Date: Date firm has been either decertified or recommended for delisting. 7. Reason for Cancellation: Check applicable box. Other denotes voluntary or seasonal suspension of activities. 8.a) State Shellfish Control Authority designee: Print name to validate signature block. 8.b) Signature of designee 8.c) Date certificate sent to FDA

Section II - Completed by Division of Cooperative Programs - FDA
Public reporting burden for this collection of information is estimated to average 6 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of the collection of information, including suggestions for reducing this burden to: DHHS / FDA / CFSAN / OC DCP, HFS-628 5100 Paint Branch Parkway College Park, MD 20740 An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.