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</colgroup>
<tbody>
<tr class="odd">
<td colspan="59"><h4 id="bulk-milk-haulersampler-evaluation-record">BULK
MILK HAULER/SAMPLER EVALUATION RECORD</h4></td>
</tr>
<tr class="even">
<td rowspan="5"></td>
<td rowspan="5"></td>
<td colspan="8"><p><strong>HAULER</strong></p>
<p><strong>SANITATION PROCEDURES</strong></p></td>
<td colspan="49"><strong>BULK TANK SAMPLING PROCEDURES</strong></td>
</tr>
<tr class="odd">
<td>1</td>
<td>2</td>
<td>3</td>
<td>4</td>
<td>5</td>
<td>6</td>
<td>7</td>
<td colspan="2">8</td>
<td>9</td>
<td colspan="2"></td>
<td>10</td>
<td colspan="3"></td>
<td>11</td>
<td></td>
<td></td>
<td>12</td>
<td colspan="2"></td>
<td>13</td>
<td colspan="2"></td>
<td colspan="2">14</td>
<td colspan="25"></td>
<td>15</td>
<td colspan="4"></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td>a</td>
<td>b</td>
<td></td>
<td>a</td>
<td>b</td>
<td>c</td>
<td></td>
<td>a</td>
<td>b</td>
<td></td>
<td>a</td>
<td>b</td>
<td></td>
<td>a</td>
<td colspan="2">b</td>
<td colspan="2"></td>
<td>a</td>
<td>b</td>
<td>c</td>
<td>d</td>
<td>e</td>
<td>f</td>
<td>g</td>
<td>h</td>
<td>i</td>
<td>j</td>
<td>k</td>
<td>l</td>
<td>m</td>
<td colspan="2"></td>
<td>n</td>
<td>o</td>
<td>p</td>
<td>q</td>
<td>r</td>
<td>s</td>
<td>t</td>
<td>u</td>
<td>v</td>
<td></td>
<td colspan="2">a</td>
<td>b</td>
<td>c</td>
</tr>
<tr class="odd">
<td rowspan="3"><blockquote>
<p>Pickup practices conducted to preclude contamination of milk contact
surfaces</p>
</blockquote></td>
<td rowspan="3"><blockquote>
<p>Hands clean and dry; no infections</p>
</blockquote></td>
<td rowspan="3"><blockquote>
<p>Clean outer clothing; no use of tobacco</p>
</blockquote></td>
<td rowspan="3"><blockquote>
<p>Hose port used; tank lids closed during completion of pickup</p>
</blockquote></td>
<td rowspan="3"><blockquote>
<p>Hose properly capped between milk pickup operations, hose cap
protected</p>
<p>during milk pickup</p>
</blockquote></td>
<td rowspan="3"><blockquote>
<p>Hose disconnected before tank rinsed</p>
</blockquote></td>
<td rowspan="3"><blockquote>
<p>Observation made for sediment/abnormalities</p>
</blockquote></td>
<td colspan="2" rowspan="3"><blockquote>
<p>Sample collected from each producer bulk tank picked up</p>
</blockquote></td>
<td rowspan="3"><blockquote>
<p><strong>Thermometer - Approved Type</strong></p>
</blockquote></td>
<td rowspan="3"><blockquote>
<p>Accuracy checked against standard thermometer every 6 months –
accuracy ± 1 division</p>
</blockquote></td>
<td rowspan="3"><blockquote>
<p>Date checked and checker’s initials attached to case</p>
</blockquote></td>
<td rowspan="3"><blockquote>
<p><strong>Sample Transfer Instrument</strong></p>
</blockquote></td>
<td rowspan="3"><blockquote>
<p>Cleaned, sanitized or sterilized and of proper construction and
repair</p>
</blockquote></td>
<td rowspan="3"><blockquote>
<p>Sterile needle for aseptically dispensing a milk sample from the bulk
milk tank<br />
sample septum</p>
</blockquote></td>
<td rowspan="3"><blockquote>
<p>An approval in-line sampler</p>
</blockquote></td>
<td rowspan="3"><blockquote>
<p><strong>Sampling Instrument Container</strong></p>
</blockquote></td>
<td rowspan="3"><blockquote>
<p>Proper design, construction and repair for storing sample dipper in
sanitizer</p>
</blockquote></td>
<td rowspan="3"><blockquote>
<p>Applicable test kit for checking strength of sanitizer (200 ppm
chlorine or</p>
<p>equivalent)</p>
</blockquote></td>
<td rowspan="3"><blockquote>
<p><strong>Sample Containers</strong></p>
</blockquote></td>
<td rowspan="3"><blockquote>
<p>Clean, properly sanitized or sterilized</p>
</blockquote></td>
<td rowspan="3"><blockquote>
<p>Adequate supply, properly stored and handled</p>
</blockquote></td>
<td rowspan="3"><blockquote>
<p><strong>Sample Storage Case</strong></p>
</blockquote></td>
<td rowspan="3"><blockquote>
<p>Rigid construction, suitable design to maintain samples at 0°-4.4°C
(32°-40°F),<br />
protected from contamination</p>
</blockquote></td>
<td colspan="2" rowspan="3"><blockquote>
<p>Ample space for refrigerant; racks provided where necessary</p>
</blockquote></td>
<td colspan="2" rowspan="3"><blockquote>
<p><strong>Sample Collection - Precautions and Procedures</strong></p>
</blockquote></td>
<td rowspan="3"><blockquote>
<p>Sampling instrument and container(s) properly carried into and
aseptically</p>
<p>handled in milk house</p>
</blockquote></td>
<td rowspan="3"><blockquote>
<p>Bulk tank milk outlet valve sanitized before connecting transfer
hose</p>
</blockquote></td>
<td rowspan="3"><blockquote>
<p>Smell milk through tank port hole</p>
</blockquote></td>
<td rowspan="3"><blockquote>
<p>Observe milk in a quiescent state with lid wide open and lights on
when necessary</p>
</blockquote></td>
<td rowspan="3"><blockquote>
<p>Test thermometer sanitized (1 minute contact time)</p>
</blockquote></td>
<td rowspan="3"><blockquote>
<p>Nonacceptable milk rejected</p>
</blockquote></td>
<td rowspan="3"><blockquote>
<p>Dry measuring stick with single-service paper towel</p>
</blockquote></td>
<td rowspan="3"><blockquote>
<p>Measure milk only when quiescent</p>
</blockquote></td>
<td rowspan="3"><blockquote>
<p>Do not contaminate milk during measuring process</p>
</blockquote></td>
<td rowspan="3"><blockquote>
<p>Agitate milk before sampling at least 5 min. or longer as may be
required by<br />
tank specifications</p>
</blockquote></td>
<td rowspan="3"><blockquote>
<p>Do not open bulk tank valve until milk is measured and sampled</p>
</blockquote></td>
<td rowspan="3"><blockquote>
<p>Temperature of milk, time, date of pickup and bulk milk
hauler/sampler name<br />
and license or permit no. and producer identification on each farm
weight ticket</p>
</blockquote></td>
<td rowspan="3"><blockquote>
<p>Tank thermometer accuracy and accuracy recording thermometer checked
monthly and recorded when used as test thermometer</p>
</blockquote></td>
<td>m1</td>
<td>m2</td>
<td rowspan="3"><blockquote>
<p>Temperature control sample provided at first sampling location for
each<br />
rack of samples</p>
</blockquote></td>
<td rowspan="3"><blockquote>
<p>Temperature control sample properly identified with time, date,
temperature,<br />
and with producer ID and bulk milk hauler/sampler identification</p>
</blockquote></td>
<td rowspan="3"><blockquote>
<p>Sample containers legibly identified at collection points</p>
</blockquote></td>
<td rowspan="3"><blockquote>
<p>Sample dipper rinsed at least two times in the milk before
transferring sample</p>
</blockquote></td>
<td rowspan="3"><blockquote>
<p>Dipper should be extended 6-8 inches into the milk to obtain
representative<br />
sample</p>
</blockquote></td>
<td rowspan="3"><blockquote>
<p>Do not hold sample container over the milk when transferring sample
into the container</p>
</blockquote></td>
<td rowspan="3"><blockquote>
<p>Fill sample container not more than 3/4 full</p>
</blockquote></td>
<td rowspan="3"><blockquote>
<p>Rinse sample dipper in safe tap water, return to storage container,
open tank<br />
valve, and start milk transfer pump</p>
</blockquote></td>
<td rowspan="3"><blockquote>
<p>Immediately take milk sample to the sample case</p>
</blockquote></td>
<td rowspan="3"><blockquote>
<p><strong>Sample collection - storage and transportation</strong></p>
</blockquote></td>
<td colspan="2" rowspan="3"><blockquote>
<p>Sample Storage – Refrigerant maintained no higher than milk level in
sample<br />
containers – maintain sample temperature 0°-4.4°C (32°-40°F); do not
bury<br />
tops of containers in ice; protect against contamination</p>
</blockquote></td>
<td rowspan="3"><blockquote>
<p>Deliver samples to laboratory promptly</p>
</blockquote></td>
<td rowspan="3"><blockquote>
<p>Samples and sample data - submitted to laboratory - if by common
carrier,<br />
use tamper-proof shipping case with top labeled "This Side Up"</p>
</blockquote></td>
</tr>
<tr class="even">
<td rowspan="2"><blockquote>
<p>Accuracy checked monthly and recorded when used as test
thermometer</p>
</blockquote></td>
<td rowspan="2"><blockquote>
<p>Accuracy of recording thermometer checked monthly against
standardizedthermometer and recorded</p>
</blockquote></td>
</tr>
<tr class="odd">
<td>SAMPLE COLLECTOR</td>
<td>DATE</td>
</tr>
<tr class="even">
<td>1.      </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>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </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>
</tr>
<tr class="odd">
<td>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>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </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>
</tr>
<tr class="even">
<td>3.      </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>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </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>
</tr>
<tr class="odd">
<td>4.      </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>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </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>
</tr>
<tr class="even">
<td>5.      </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>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </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>
</tr>
<tr class="odd">
<td>6.      </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>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </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>
</tr>
<tr class="even">
<td>7.      </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>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </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>
</tr>
<tr class="odd">
<td>8.      </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>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </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>
</tr>
<tr class="even">
<td>9.      </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>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </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>
</tr>
<tr class="odd">
<td>10.      </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>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </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>
</tr>
<tr class="even">
<td>11.      </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>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </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>
</tr>
<tr class="odd">
<td>12.      </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>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </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>
</tr>
<tr class="even">
<td>13.      </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>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </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>
</tr>
<tr class="odd">
<td>14.      </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>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </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>
</tr>
<tr class="even">
<td>15.      </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>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </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>
</tr>
<tr class="odd">
<td><strong>Sub-Total</strong> 0</td>
<td>     </td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td colspan="2">0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td colspan="2">0</td>
<td colspan="2">0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td colspan="2">0</td>
<td>0</td>
<td>0</td>
<td>0</td>
</tr>
<tr class="even">
<td><strong>Total</strong> 0</td>
<td>     </td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td colspan="2">0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td colspan="2">0</td>
<td colspan="2">0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td>0</td>
<td colspan="2">0</td>
<td>0</td>
<td>0</td>
<td>0</td>
</tr>
<tr class="odd">
<td><strong>% Compliance</strong>      </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>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td colspan="2">   </td>
<td colspan="2">   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </td>
<td>   </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>
</tr>
<tr class="even">
<td colspan="59"><strong>F</strong><strong>ORM FDA 2399c
(10/06)</strong> PREVIOUS EDITIONS ARE OBSOLETE PSC Graphics: (301)
443-1090 EF</td>
</tr>
<tr class="odd">
<td colspan="59">SANITARIAN: <u>     </u> AGENCY: <u>     </u> DATE:
<u>     </u></td>
</tr>
</tbody>
</table>