<table>
<colgroup>
<col style="width: 5%" />
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 4%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 2%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 7%" />
<col style="width: 7%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="42">U.S. Department of Health and Human Services</td>
</tr>
<tr class="even">
<td colspan="42">Food and Drug Administration</td>
</tr>
<tr class="odd">
<td>Milk Plant</td>
<td colspan="12">     </td>
<td colspan="29"><strong>STATUS OF MILK PLANTS</strong></td>
</tr>
<tr class="even">
<td colspan="2">Date of Rating</td>
<td colspan="11">     </td>
<td colspan="28">(INCLUDING DRYING AND CONDENSING MILK PRODUCTS PLANTS,
Sanitation Compliance Rating<sup>1</sup></td>
<td>     </td>
</tr>
<tr class="odd">
<td colspan="42">RECEIVING STATIONS and TRANSFER STATIONS)</td>
</tr>
<tr class="even">
<td colspan="3" rowspan="3"><p><strong>NAME OF PLANT/</strong></p>
<p><strong>(MILK PRODUCT/<br />
PASTEURIZATION/</strong></p>
<p><strong>FILING AND</strong></p>
<p><strong>CAPPING)</strong></p></td>
<td rowspan="3"><blockquote>
<p>Pounds Processed Daily</p>
<p>(100# Units)3</p>
</blockquote></td>
<td colspan="33"><strong>ITEMS OF SANITATION</strong></td>
<td></td>
<td></td>
<td></td>
<td colspan="2" rowspan="3"><strong>REMARKS</strong></td>
</tr>
<tr class="odd">
<td rowspan="2"><blockquote>
<p>Floors</p>
</blockquote></td>
<td rowspan="2"><blockquote>
<p>Walls and Ceilings</p>
</blockquote></td>
<td colspan="2" rowspan="2"><blockquote>
<p>Doors and Windows</p>
</blockquote></td>
<td rowspan="2"><blockquote>
<p>Lighting</p>
</blockquote></td>
<td rowspan="2"><blockquote>
<p>Ventilation</p>
</blockquote></td>
<td rowspan="2"><blockquote>
<p>Separate Rooms</p>
</blockquote></td>
<td rowspan="2"><blockquote>
<p>Toilet/Sewage<br />
Disposal Facilities</p>
</blockquote></td>
<td colspan="2" rowspan="2"><blockquote>
<p>Water Supply</p>
</blockquote></td>
<td rowspan="2"><blockquote>
<p>Handwashing Facilities</p>
</blockquote></td>
<td rowspan="2"><blockquote>
<p>Milk Plant Cleanliness</p>
</blockquote></td>
<td rowspan="2"><blockquote>
<p>Sanitary Piping</p>
</blockquote></td>
<td colspan="4"><p><strong>Containers and</strong></p>
<p><strong>Equipment</strong></p></td>
<td colspan="2" rowspan="2"><blockquote>
<p>Storage of Single- Service Articles</p>
</blockquote></td>
<td colspan="2" rowspan="2"><blockquote>
<p>Protection From</p>
<p>Contamination</p>
</blockquote></td>
<td colspan="5"><strong>Pasteurization</strong></td>
<td></td>
<td colspan="2"><strong>Bottling<br />
Capping</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><blockquote>
<p>Construction and Repair</p>
</blockquote></td>
<td><blockquote>
<p>Cleaning</p>
</blockquote></td>
<td><blockquote>
<p>Sanitization</p>
</blockquote></td>
<td><blockquote>
<p>Storage of Clean Equipment</p>
</blockquote></td>
<td><blockquote>
<p>Indicating and<br />
Recording Thermometers</p>
</blockquote></td>
<td><blockquote>
<p>Time and Temperature</p>
<p>Controls</p>
</blockquote></td>
<td><blockquote>
<p>Adulteration Controls</p>
</blockquote></td>
<td><blockquote>
<p>Regenerative Heating</p>
</blockquote></td>
<td><blockquote>
<p>Temperature Recording<br />
Charts</p>
</blockquote></td>
<td><blockquote>
<p>Cooling</p>
</blockquote></td>
<td colspan="2"><blockquote>
<p>Container Filing,<br />
Capping and Sealing</p>
</blockquote></td>
<td><blockquote>
<p>Personnel Cleanliness</p>
<p>Protective Clothing</p>
</blockquote></td>
<td><blockquote>
<p>Vehicles</p>
</blockquote></td>
<td><blockquote>
<p>Surroundings</p>
</blockquote></td>
<td><blockquote>
<p>Bacterial Count*</p>
</blockquote></td>
<td><blockquote>
<p>Coliform Count*</p>
</blockquote></td>
<td><blockquote>
<p>Total Debits <sup>2</sup></p>
</blockquote></td>
<td><blockquote>
<p>Pounds Processed Daily<br />
(100# Units)3 X TotalDebits<sup>2</sup></p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="3" rowspan="3"></td>
<td rowspan="2"><strong>ITEM</strong></td>
<td rowspan="2">1</td>
<td rowspan="2">2</td>
<td colspan="2" rowspan="2">3</td>
<td rowspan="2">4a</td>
<td rowspan="2">4b</td>
<td rowspan="2">5</td>
<td rowspan="2">6</td>
<td colspan="2" rowspan="2">7</td>
<td rowspan="2">8</td>
<td rowspan="2">9</td>
<td rowspan="2">10</td>
<td rowspan="2">11</td>
<td rowspan="2">12ab</td>
<td rowspan="2">12c-f</td>
<td rowspan="2">13</td>
<td colspan="2" rowspan="2">14</td>
<td rowspan="2">15a</td>
<td rowspan="2">15b</td>
<td colspan="2">16abc</td>
<td rowspan="2">16b-c</td>
<td rowspan="2">16d</td>
<td rowspan="2">16e</td>
<td rowspan="2">17</td>
<td rowspan="2">18</td>
<td rowspan="2">19</td>
<td rowspan="2">20</td>
<td rowspan="2">21</td>
<td rowspan="2">22</td>
<td rowspan="2"></td>
<td rowspan="2"></td>
<td rowspan="2"></td>
<td rowspan="2"></td>
<td colspan="2" rowspan="3"></td>
</tr>
<tr class="even">
<td>(1)</td>
<td>(2)</td>
</tr>
<tr class="odd">
<td><strong>WEIGHT</strong></td>
<td>1</td>
<td>1</td>
<td colspan="2">2</td>
<td>1</td>
<td>1</td>
<td>3</td>
<td>3</td>
<td colspan="2">4</td>
<td>2</td>
<td>3</td>
<td>3</td>
<td>3</td>
<td>5</td>
<td>5</td>
<td>3</td>
<td colspan="2">2</td>
<td>3</td>
<td>5</td>
<td>4</td>
<td>15</td>
<td>3</td>
<td>10</td>
<td>4</td>
<td>5</td>
<td colspan="2">5</td>
<td>1</td>
<td>1</td>
<td>2</td>
<td>5*</td>
<td>10*</td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="3">     </td>
<td><strong>    </strong></td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">     </td>
</tr>
<tr class="odd">
<td colspan="3"><strong>     </strong></td>
<td><strong>    </strong></td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">     </td>
</tr>
<tr class="even">
<td colspan="3"><strong>     </strong></td>
<td><strong>    </strong></td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">     </td>
</tr>
<tr class="odd">
<td colspan="3"><strong>     </strong></td>
<td><strong>    </strong></td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">     </td>
</tr>
<tr class="even">
<td colspan="3"><strong>     </strong></td>
<td><strong>    </strong></td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">     </td>
</tr>
<tr class="odd">
<td colspan="3"><strong>     </strong></td>
<td><strong>    </strong></td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">     </td>
</tr>
<tr class="even">
<td colspan="3"><strong>     </strong></td>
<td><strong>    </strong></td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">     </td>
</tr>
<tr class="odd">
<td colspan="3"><strong>     </strong></td>
<td><strong>    </strong></td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">     </td>
</tr>
<tr class="even">
<td colspan="3"><strong>     </strong></td>
<td><strong>    </strong></td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">     </td>
</tr>
<tr class="odd">
<td colspan="3"><strong>     </strong></td>
<td><strong>    </strong></td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">     </td>
</tr>
<tr class="even">
<td colspan="3"><strong>     </strong></td>
<td><strong>    </strong></td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">     </td>
</tr>
<tr class="odd">
<td colspan="3"><strong>     </strong></td>
<td><strong>    </strong></td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">     </td>
</tr>
<tr class="even">
<td colspan="3"><strong>     </strong></td>
<td><strong>    </strong></td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">     </td>
</tr>
<tr class="odd">
<td colspan="3"><strong>     </strong></td>
<td><strong>    </strong></td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">     </td>
</tr>
<tr class="even">
<td colspan="3"><strong>     </strong></td>
<td><strong>    </strong></td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">     </td>
</tr>
<tr class="odd">
<td colspan="3"><strong>TOTALS</strong></td>
<td><strong>0</strong></td>
<td><strong>0</strong></td>
<td><strong>0</strong></td>
<td colspan="2"><strong>0</strong></td>
<td><strong>0</strong></td>
<td><strong>0</strong></td>
<td><strong>0</strong></td>
<td><strong>0</strong></td>
<td colspan="2"><strong>0</strong></td>
<td><strong>0</strong></td>
<td><strong>0</strong></td>
<td><strong>0</strong></td>
<td><strong>0</strong></td>
<td><strong>0</strong></td>
<td><strong>0</strong></td>
<td><strong>0</strong></td>
<td colspan="2"><strong>0</strong></td>
<td><strong>0</strong></td>
<td><strong>0</strong></td>
<td><strong>0</strong></td>
<td><strong>0</strong></td>
<td><strong>0</strong></td>
<td><strong>0</strong></td>
<td><strong>0</strong></td>
<td><strong>0</strong></td>
<td colspan="2"><strong>0</strong></td>
<td><strong>0</strong></td>
<td><strong>0</strong></td>
<td><strong>0</strong></td>
<td><strong>0</strong></td>
<td><strong>0</strong></td>
<td><strong>0</strong></td>
<td><strong>0</strong></td>
<td colspan="2">     </td>
</tr>
<tr class="even">
<td colspan="7" rowspan="2"><p>Footnotes:</p>
<p><sup>1</sup><em>Sanitation Compliance Rating = 100 –</em></p></td>
<td colspan="15"><em>Total Pounds Processed Daily (100#
Units)<sup>3</sup> X Total Debits<sup>2</sup></em></td>
<td colspan="20" rowspan="2"><blockquote>
<p><sup>2</sup> Total Debits for each milk plant, receiving station or
transfer station is the sum of the weights of the Items violated.<br />
(<strong>NOTE:</strong> Any Item or sub-item violated, indicate by
placing the debit value (weight) of that Item or an “X” under that
Item.)</p>
<p><sup>3</sup> Total Pounds Processed Daily are calculated in 100#
Units.</p>
<p>* Used only when not in compliance. Prorate by product.</p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="15"><em>Total Pounds Processed Daily (100#
Units)<sup>3</sup></em></td>
</tr>
</tbody>
</table>