<table style="width:100%;">
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<tbody>
<tr class="odd">
<td colspan="7" rowspan="2"><p><strong>Department of</strong>
<strong>Health and Human Services</strong></p>
<p>FOOD AND DRUG ADMINISTRATION</p></td>
<td colspan="26" rowspan="2"><p><strong>INTERSTATE MILK SHIPPER’s
REPORT</strong></p>
<p><em>(Submit an original and two (2)</em></p>
<p><em>copies to the FDA Regional Office)</em></p></td>
<td colspan="9"><strong>3-A. COUNTRY</strong></td>
</tr>
<tr class="even">
<td colspan="9">     </td>
</tr>
<tr class="odd">
<td colspan="13">1. <strong>NAME OF SHIPPER</strong></td>
<td colspan="18">2. <strong>CITY</strong></td>
<td colspan="11">3. <strong>STATE</strong></td>
</tr>
<tr class="even">
<td colspan="13">     </td>
<td colspan="18">     </td>
<td colspan="11">     </td>
</tr>
<tr class="odd">
<td colspan="9">4. <strong>STREET</strong></td>
<td>5.</td>
<td colspan="14"><strong>PLANT or BTU #</strong></td>
<td colspan="2">6.</td>
<td colspan="16"><strong>PRODUCT CODE #s</strong></td>
</tr>
<tr class="even">
<td colspan="9">     </td>
<td> </td>
<td colspan="2"> </td>
<td colspan="3"> </td>
<td colspan="2"> </td>
<td colspan="3"> </td>
<td colspan="2"> </td>
<td> </td>
<td> </td>
<td colspan="2"> </td>
<td> </td>
<td colspan="2"> </td>
<td colspan="3"> </td>
<td colspan="2"> </td>
<td colspan="2"> </td>
<td colspan="2"> </td>
<td> </td>
<td colspan="2"> </td>
<td> </td>
</tr>
<tr class="odd">
<td colspan="42">7. <strong>SURVEY DATA</strong></td>
</tr>
<tr class="even">
<td colspan="2" rowspan="2"></td>
<td colspan="4">DAIRY FARMS</td>
<td colspan="10" rowspan="2"><p>RECEIVING OR</p>
<p>TRANSFER STATION</p></td>
<td colspan="10" rowspan="2">MILK PLANT <sup>1</sup></td>
<td colspan="16" rowspan="2">ENFORCEMENT</td>
</tr>
<tr class="odd">
<td colspan="4"><p>TYPE OF RATING</p>
<p> AREA INDIVIDUAL</p></td>
</tr>
<tr class="even">
<td colspan="2">RATING <em>(%)</em></td>
<td colspan="4">     </td>
<td colspan="10">     </td>
<td colspan="10">     </td>
<td colspan="16">     </td>
</tr>
<tr class="odd">
<td colspan="2">DATE OF RATING</td>
<td colspan="4">     </td>
<td colspan="10">     </td>
<td colspan="10">     </td>
<td colspan="16">     </td>
</tr>
<tr class="even">
<td colspan="2">TOTAL NUMBER</td>
<td colspan="4">     </td>
<td colspan="10">     </td>
<td colspan="10">     </td>
<td colspan="16" rowspan="3"><p>APPENDIX N</p>
<p>IS THE SHIPPER IN COMPLIANCE WITH THE</p>
<p>PROVISIONS OF APPENDIX N?</p>
<p> YES NO</p></td>
</tr>
<tr class="odd">
<td colspan="2">NUMBER INSPECTED</td>
<td colspan="4">     </td>
<td colspan="10">     </td>
<td colspan="10">     </td>
</tr>
<tr class="even">
<td colspan="2">VOLUME RECEIVE<br />
DAILY <em>(Cwt)</em></td>
<td colspan="4"></td>
<td colspan="10">     </td>
<td colspan="10">     </td>
</tr>
<tr class="odd">
<td colspan="2">RATING AGENCY</td>
<td colspan="14">CERTIFIED STATE RATING OFFICER</td>
<td colspan="10" rowspan="2"><p>OFFICER’S CERTIFICATION</p>
<p>EXPIRATION DATE</p></td>
<td colspan="16" rowspan="2">EARLIEST RATING DATE</td>
</tr>
<tr class="even">
<td colspan="2" rowspan="3"><p> SHD</p>
<p> SDA</p>
<p> OTHER      </p></td>
<td colspan="14" rowspan="3">     </td>
</tr>
<tr class="odd">
<td colspan="10" rowspan="2">     </td>
<td colspan="6">MONTH</td>
<td colspan="6">DAY</td>
<td colspan="4">YEAR</td>
</tr>
<tr class="even">
<td colspan="2"> </td>
<td colspan="4"> </td>
<td colspan="3"> </td>
<td colspan="3"> </td>
<td colspan="2"> </td>
<td colspan="2"> </td>
</tr>
<tr class="odd">
<td colspan="42">AGENCY PROVIDING CONTINUOUS SUPERVISION OF SUPPLY</td>
</tr>
<tr class="even">
<td colspan="42">     </td>
</tr>
<tr class="odd">
<td colspan="42">8. <strong>LABORATORY CONTROL</strong></td>
</tr>
<tr class="even">
<td colspan="3">APPROVED LABORATORY NUMBER</td>
<td colspan="5">EXPIRATION DATE</td>
<td colspan="17">PROCESSED MILK TESTS APPROVED</td>
<td colspan="17">RAW MILK TESTS APPROVED</td>
</tr>
<tr class="odd">
<td colspan="3">A.      </td>
<td colspan="5">A.      </td>
<td colspan="3" rowspan="2">SPC</td>
<td colspan="3" rowspan="2">COLI</td>
<td colspan="5" rowspan="2">PHOS</td>
<td colspan="2" rowspan="2">RBC</td>
<td colspan="4" rowspan="2"><p>DRUG RESIDUE</p>
<p>TESTS</p></td>
<td colspan="5" rowspan="2"><p>VIABLE</p>
<p>COUNTS</p></td>
<td colspan="7" rowspan="2"><p>SOMATIC</p>
<p>CELL COUNTS</p></td>
<td colspan="5" rowspan="2"><p>DRUG RESIDUE</p>
<p>TESTS</p></td>
</tr>
<tr class="even">
<td colspan="3">B.      </td>
<td colspan="5">B.      </td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="5"></td>
<td colspan="3">A.    </td>
<td colspan="3">A.    </td>
<td colspan="5">A.    </td>
<td colspan="2">A.    </td>
<td colspan="4">A.      </td>
<td colspan="5">A.    </td>
<td colspan="7">A.      </td>
<td colspan="5">A.      </td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="5"></td>
<td colspan="3">B.    </td>
<td colspan="3">B.    </td>
<td colspan="5">B.    </td>
<td colspan="2">B.    </td>
<td colspan="4">B.      </td>
<td colspan="5">B.    </td>
<td colspan="7">B.      </td>
<td colspan="5">B.      </td>
</tr>
<tr class="odd">
<td colspan="8">DATE OF LAST TWO (2) SPLIT SAMPLES</td>
<td colspan="17">APPROVED WATER LABORATORY AND DATE</td>
<td colspan="17">WATER TESTS APPROVED</td>
</tr>
<tr class="even">
<td>A.      </td>
<td colspan="7">A.      </td>
<td colspan="17" rowspan="2">     </td>
<td colspan="17" rowspan="2">     </td>
</tr>
<tr class="odd">
<td>B.      </td>
<td colspan="7">B.      </td>
</tr>
<tr class="even">
<td colspan="42">9. <strong>PUBLICATION</strong> <em>(Written permission
from a shipper must be filed at a Regional Office of FDA prior to the
publication of a rating.)</em></td>
</tr>
<tr class="odd">
<td colspan="42">LETTER OF PERMISSION TO PUBLISH IS TRANSMITTED WITH
THIS REPORT? YES NO</td>
</tr>
<tr class="even">
<td colspan="42">10. <strong>SUBMISSION OF REPORT BY STATE
AGENCY</strong></td>
</tr>
<tr class="odd">
<td colspan="4">DATE OF REPORT</td>
<td colspan="38">SUBMITTED BY <em>(Signature and Title)</em></td>
</tr>
<tr class="even">
<td colspan="4">     </td>
<td colspan="38">     </td>
</tr>
<tr class="odd">
<td colspan="42"><strong>FOR FDA REGIONAL OFFICE USE ONLY</strong></td>
</tr>
<tr class="even">
<td colspan="5" rowspan="2">Written permission from shipper dated</td>
<td colspan="13">     </td>
<td colspan="24" rowspan="2">on file and publication of rating/listing
recommended.</td>
</tr>
<tr class="odd">
<td colspan="13"></td>
</tr>
<tr class="even">
<td colspan="4">DATE</td>
<td colspan="38">SUBMITTED BY <em>(FDA Milk Specialist)</em></td>
</tr>
<tr class="odd">
<td colspan="4">     </td>
<td colspan="38">     </td>
</tr>
<tr class="even">
<td colspan="42"><sup>1</sup> Submit separate Form for each milk
plant.</td>
</tr>
</tbody>
</table>

+-----------------------+--------------+--------+------+-------+-----+
| 11\. **MILK PLANTS**: |              |        |      |       |     |
| List below the Name   |              |        |      |       |     |
| and Address of all    |              |        |      |       |     |
| shippers of raw milk  |              |        |      |       |     |
| received during the   |              |        |      |       |     |
| thirty (30) days      |              |        |      |       |     |
| preceding the date of |              |        |      |       |     |
| the Rating; Volume in |              |        |      |       |     |
| Hundredweight (cwt);  |              |        |      |       |     |
| Sanitation Compliance |              |        |      |       |     |
| Rating; and Date of   |              |        |      |       |     |
| Rating. Plants        |              |        |      |       |     |
| receiving milk from   |              |        |      |       |     |
| unlisted sources, or  |              |        |      |       |     |
| sources below 90, are |              |        |      |       |     |
| not eligible for      |              |        |      |       |     |
| listing on the        |              |        |      |       |     |
| electronic            |              |        |      |       |     |
| publication, *IMS     |              |        |      |       |     |
| LIST -- SANITATION    |              |        |      |       |     |
| COMPLIANCE AND        |              |        |      |       |     |
| ENFORCEMENT RATINGS   |              |        |      |       |     |
| OF INTERSTATE MILK    |              |        |      |       |     |
| ­SHIPPERS*.            |              |        |      |       |     |
+-----------------------+--------------+--------+------+-------+-----+
| **NAME OF SHIPPER**   | **CITY AND   |        | **   | **    | **D |
|                       | STATE**      |        | VOLU | SANIT | ATE |
|                       |              |        | ME** | ATION | OF  |
|                       |              |        |      | COMPL | RA  |
|                       |              |        | (    | IANCE | TIN |
|                       |              |        | cwt) | RAT   | G** |
|                       |              |        |      | ING** |     |
+-----------------------+--------------+--------+------+-------+-----+
|                       |              |        |      |       |     |
|                       |              |        |      |       |     |
+-----------------------+--------------+--------+------+-------+-----+
|                       |              |        |      |       |     |
|                       |              |        |      |       |     |
+-----------------------+--------------+--------+------+-------+-----+
|                       |              |        |      |       |     |
|                       |              |        |      |       |     |
+-----------------------+--------------+--------+------+-------+-----+
|                       |              |        |      |       |     |
|                       |              |        |      |       |     |
+-----------------------+--------------+--------+------+-------+-----+
|                       |              |        |      |       |     |
|                       |              |        |      |       |     |
+-----------------------+--------------+--------+------+-------+-----+
|                       |              |        |      |       |     |
|                       |              |        |      |       |     |
+-----------------------+--------------+--------+------+-------+-----+
|                       |              |        |      |       |     |
|                       |              |        |      |       |     |
+-----------------------+--------------+--------+------+-------+-----+
|                       |              |        |      |       |     |
|                       |              |        |      |       |     |
+-----------------------+--------------+--------+------+-------+-----+
|                       |              |        |      |       |     |
|                       |              |        |      |       |     |
+-----------------------+--------------+--------+------+-------+-----+
|                       |              |        |      |       |     |
|                       |              |        |      |       |     |
+-----------------------+--------------+--------+------+-------+-----+
|                       |              |        |      |       |     |
|                       |              |        |      |       |     |
+-----------------------+--------------+--------+------+-------+-----+
|                       |              |        |      |       |     |
|                       |              |        |      |       |     |
+-----------------------+--------------+--------+------+-------+-----+
|                       |              |        |      |       |     |
|                       |              |        |      |       |     |
+-----------------------+--------------+--------+------+-------+-----+
|                       |              |        |      |       |     |
|                       |              |        |      |       |     |
+-----------------------+--------------+--------+------+-------+-----+
|                       |              |        |      |       |     |
|                       |              |        |      |       |     |
+-----------------------+--------------+--------+------+-------+-----+
| **INSTRUCTIONS:**     |              |        |      |       |     |
|                       |              |        |      |       |     |
| Completed Forms must  |              |        |      |       |     |
| be received by the    |              |        |      |       |     |
| Milk Safety Branch    |              |        |      |       |     |
| (HFS-626) 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:         |              |        |      |       |     |
+-----------------------+--------------+--------+------+-------+-----+
| 1\. Raw Milk for      |              | 22\.   |      |       |     |
| Pasteurization (May   |              | Dry    |      |       |     |
| include Lowfat, Skim  |              | Milk   |      |       |     |
| or Cream)             |              | and    |      |       |     |
|                       |              | Milk   |      |       |     |
| 2\. Pasteurized Milk, |              | Pr     |      |       |     |
| Reduced Fat, Lowfat,  |              | oducts |      |       |     |
| or Skim               |              |        |      |       |     |
|                       |              | 23\.   |      |       |     |
| 3\. Heat-Treated (May |              | Anh    |      |       |     |
| include Reduced Fat,  |              | ydrous |      |       |     |
| Lowfat, Skim or       |              | Milk   |      |       |     |
| Cream)                |              | Fat    |      |       |     |
|                       |              |        |      |       |     |
| 4\. Pasteurized Half  |              | 24\.   |      |       |     |
| & Half, Coffee Cream, |              | Chole  |      |       |     |
| Creams                |              | sterol |      |       |     |
|                       |              | Mo     |      |       |     |
| 5\. Ultra-Pasteurized |              | dified |      |       |     |
| (UP) Milk and Milk    |              | Anh    |      |       |     |
| Products              |              | ydrous |      |       |     |
|                       |              | Milk   |      |       |     |
| 6\. Aseptic Milk and  |              | Fat    |      |       |     |
| Milk Products         |              |        |      |       |     |
| (Including Flavored)  |              | 25\.   |      |       |     |
|                       |              | Chole  |      |       |     |
| 7\. Cottage Cheese    |              | sterol |      |       |     |
| (Including Lowfat,    |              | Mo     |      |       |     |
| Nonfat or Dry Curd)   |              | dified |      |       |     |
|                       |              | Fluid  |      |       |     |
| 8\. Cultured or       |              | Milk   |      |       |     |
| Acidified Milk and    |              | Pr     |      |       |     |
| Milk Products         |              | oducts |      |       |     |
|                       |              |        |      |       |     |
| 9\. Yogurt (Including |              | 26\.   |      |       |     |
| Lowfat or Skim)       |              | Cream  |      |       |     |
|                       |              | (Con   |      |       |     |
| 10\. Sour Cream       |              | densed |      |       |     |
| Products (Acidified   |              | or     |      |       |     |
| or Cultured)          |              | Dry)   |      |       |     |
|                       |              |        |      |       |     |
| 11\. Whey (Liquid)    |              | 27\.   |      |       |     |
|                       |              | B      |      |       |     |
| 12\. Whey (Condensed) |              | lended |      |       |     |
|                       |              | Dry    |      |       |     |
| 13\. Whey (Dry)       |              | Pr     |      |       |     |
|                       |              | oducts |      |       |     |
| 14\. Modified Whey    |              |        |      |       |     |
| Products (Condensed   |              | 28\.   |      |       |     |
| or Dry)               |              | Whey   |      |       |     |
|                       |              | Cream  |      |       |     |
| 15\. Condensed Milk   |              |        |      |       |     |
| and Milk Products     |              | 29\.   |      |       |     |
|                       |              | Whey   |      |       |     |
| 16\. Nonfat Dry Milk  |              | Cream  |      |       |     |
|                       |              | and    |      |       |     |
| 17\. Buttermilk       |              | Cream  |      |       |     |
| (Condensed or Dry)    |              | Blends |      |       |     |
|                       |              |        |      |       |     |
| 18\. Eggnog           |              | 30\.   |      |       |     |
|                       |              | Grade  |      |       |     |
| 19\. Lactose Reduced  |              | \"A\"  |      |       |     |
| Milk and Milk         |              | L      |      |       |     |
| Products              |              | actose |      |       |     |
|                       |              |        |      |       |     |
| 20\. Low-Sodium Milk  |              | 31\.   |      |       |     |
| and Milk Products     |              | Raw    |      |       |     |
|                       |              | Goat   |      |       |     |
| 21\. Milk and Milk    |              | Milk   |      |       |     |
| Products with Added   |              | for    |      |       |     |
| Safe and Suitable     |              | Pa     |      |       |     |
| Microbial Organisms\  |              | steuri |      |       |     |
| (Such as              |              | zation |      |       |     |
| Lactobacillus         |              |        |      |       |     |
| acidophilus)          |              | 32\.   |      |       |     |
|                       |              | Paste  |      |       |     |
|                       |              | urized |      |       |     |
|                       |              | Goat   |      |       |     |
|                       |              | Milk   |      |       |     |
|                       |              | and    |      |       |     |
|                       |              | Milk   |      |       |     |
|                       |              | Pr     |      |       |     |
|                       |              | oducts |      |       |     |
|                       |              |        |      |       |     |
|                       |              | 33\.   |      |       |     |
|                       |              | Cu     |      |       |     |
|                       |              | ltured |      |       |     |
|                       |              | Goat   |      |       |     |
|                       |              | Milk   |      |       |     |
|                       |              | and    |      |       |     |
|                       |              | Milk   |      |       |     |
|                       |              | Pr     |      |       |     |
|                       |              | oducts |      |       |     |
|                       |              |        |      |       |     |
|                       |              | 34\.   |      |       |     |
|                       |              | Con    |      |       |     |
|                       |              | densed |      |       |     |
|                       |              | or Dry |      |       |     |
|                       |              | Goat   |      |       |     |
|                       |              | Milk   |      |       |     |
|                       |              | and    |      |       |     |
|                       |              | Milk   |      |       |     |
|                       |              | Pr     |      |       |     |
|                       |              | oducts |      |       |     |
|                       |              |        |      |       |     |
|                       |              | 35\.   |      |       |     |
|                       |              | Ultra  |      |       |     |
|                       |              | -Paste |      |       |     |
|                       |              | urized |      |       |     |
|                       |              | (UP)   |      |       |     |
|                       |              | Goat   |      |       |     |
|                       |              | Milk   |      |       |     |
|                       |              | and    |      |       |     |
|                       |              | Milk   |      |       |     |
|                       |              | Pr     |      |       |     |
|                       |              | oducts |      |       |     |
|                       |              |        |      |       |     |
|                       |              | 36\.   |      |       |     |
|                       |              | A      |      |       |     |
|                       |              | septic |      |       |     |
|                       |              | Goat   |      |       |     |
|                       |              | Milk   |      |       |     |
|                       |              | and    |      |       |     |
|                       |              | Milk   |      |       |     |
|                       |              | Pr     |      |       |     |
|                       |              | oducts |      |       |     |
|                       |              |        |      |       |     |
|                       |              | 37\.   |      |       |     |
|                       |              | Raw    |      |       |     |
|                       |              | Sheep  |      |       |     |
|                       |              | Milk   |      |       |     |
|                       |              | for    |      |       |     |
|                       |              | Pa     |      |       |     |
|                       |              | steuri |      |       |     |
|                       |              | zation |      |       |     |
|                       |              |        |      |       |     |
|                       |              | 38\.   |      |       |     |
|                       |              | Cu     |      |       |     |
|                       |              | ltured |      |       |     |
|                       |              | Sheep  |      |       |     |
|                       |              | Milk   |      |       |     |
|                       |              | and    |      |       |     |
|                       |              | Milk   |      |       |     |
|                       |              | Pr     |      |       |     |
|                       |              | oducts |      |       |     |
|                       |              |        |      |       |     |
|                       |              | 39\.   |      |       |     |
|                       |              | Concen |      |       |     |
|                       |              | trated |      |       |     |
|                       |              | Raw    |      |       |     |
|                       |              | Milk   |      |       |     |
|                       |              | Pr     |      |       |     |
|                       |              | oducts |      |       |     |
|                       |              | for    |      |       |     |
|                       |              | Pa     |      |       |     |
|                       |              | steuri |      |       |     |
|                       |              | zation |      |       |     |
|                       |              |        |      |       |     |
|                       |              | 40\.   |      |       |     |
|                       |              | Concen |      |       |     |
|                       |              | trated |      |       |     |
|                       |              | Paste  |      |       |     |
|                       |              | urized |      |       |     |
|                       |              | Milk   |      |       |     |
|                       |              | Pr     |      |       |     |
|                       |              | oducts |      |       |     |
|                       |              |        |      |       |     |
|                       |              | 41\.   |      |       |     |
|                       |              | Ul     |      |       |     |
|                       |              | tra-Fi |      |       |     |
|                       |              | ltered |      |       |     |
|                       |              | (UF)   |      |       |     |
|                       |              | Pe     |      |       |     |
|                       |              | rmeate |      |       |     |
|                       |              | from   |      |       |     |
|                       |              | Milk   |      |       |     |
|                       |              |        |      |       |     |
|                       |              | 42\.   |      |       |     |
|                       |              | Ul     |      |       |     |
|                       |              | tra-Fi |      |       |     |
|                       |              | ltered |      |       |     |
|                       |              | (UF)   |      |       |     |
|                       |              | Pe     |      |       |     |
|                       |              | rmeate |      |       |     |
|                       |              | from   |      |       |     |
|                       |              | Whey   |      |       |     |
+-----------------------+--------------+--------+------+-------+-----+