+------------------------+---------+---------------+------------------+
| **DEPARTMENT OF HEALTH | BULK    |               | TANKER PERMIT    |
| AND HUMAN SERVICES\    | MILK    |               | NO.              |
| **FOOD AND DRUG        | HAULER  |               |                  |
| ADMINISTRATION         | /       |               |                  |
|                        | SAMPLER |               |                  |
| **BULK MILK            | PERMIT  |               |                  |
| HAULER/SAMPLER         | NO.     |               |                  |
| EVALUATION REPORT**    |         |               |                  |
|                        |         |               |                  |
+------------------------+---------+---------------+------------------+
|                        | BULK    |               | DAILY PICKUP NO. |
|                        | MILK    |               |                  |
|                        | HAULER  |               |                  |
|                        | /       |               |                  |
|                        | SAMPLER |               |                  |
|                        |         |               |                  |
|                        |         |               |                  |
+------------------------+---------+---------------+------------------+
| ADDRESS OF BULK MILK   |         | NAME AND      |                  |
| HAULER / SAMPLER       |         | ADDRESS OF    |                  |
|                        |         | INSPECTION    |                  |
|                        |         | LOCATION      |                  |
|                        |         |               |                  |
|                        |         |               |                  |
+------------------------+---------+---------------+------------------+
| OWNER                  |         |               |                  |
|                        |         |               |                  |
|                        |         |               |                  |
+------------------------+---------+---------------+------------------+
|                        |         | NAME AND      |                  |
|                        |         | ADDRESS OF    |                  |
|                        |         | RECEIVING     |                  |
|                        |         | PLANT         |                  |
|                        |         |               |                  |
|                        |         |               |                  |
+------------------------+---------+---------------+------------------+
| ADDRESS OF OWNER       |         |               |                  |
|                        |         |               |                  |
|                        |         |               |                  |
+------------------------+---------+---------------+------------------+
| > ***An evaluation of  |         |               |                  |
| > your sampling        |         |               |                  |
| > procedures showed    |         |               |                  |
| > violations existing  |         |               |                  |
| > in the Items checked |         |               |                  |
| > below. You are       |         |               |                  |
| > further notified     |         |               |                  |
| > that this evalua-    |         |               |                  |
| > tion report serves   |         |               |                  |
| > as notification of   |         |               |                  |
| > the intent to        |         |               |                  |
| > suspend your permit  |         |               |                  |
| > if the violations    |         |               |                  |
| > noted are not in     |         |               |                  |
| > compliance at the    |         |               |                  |
| > time of the next     |         |               |                  |
| > inspection. (Refer   |         |               |                  |
| > to Sections 3 and 5  |         |               |                  |
| > of the Grade "A"     |         |               |                  |
| > Pasteurized Milk     |         |               |                  |
| > Ordinance.)***       |         |               |                  |
+------------------------+---------+---------------+------------------+

**HAULER SANITATION PROCEDURES**

1\. Pickup practices conducted to preclude contamination of milk\
contact surfaces

2\. Hands clean and dry, no infections \
3. Clean outer clothing, no use of tobacco \
4. Hose port used, tank lids closed during completion of pickup \
5. Hose properly capped between milk pickup operations, hose cap\
protected during milk pickup \
6. Hose disconnected before tank rinsed \
7. Observations made for sediment/abnormalities \
8. Sample collected from each producer bulk tank picked up

**BULK TANK SAMPLING PROCEDURES**

9\. Thermometer -- Approved Type \
a. Accuracy -- Checked against standard thermometer every 6\
months -- accuracy (+) (-) division

b\. Date checked and checker's initials attached to case \
10. Sample Transfer Instrument

a\. Clean, sanitized or sterilized and of proper construction and repair

b\. Sterile needle for aseptically dispensing a milk sample from\
the bulk tank sample septum into a sample container (i.e., vial) a.

c\. An approved in-line sample

11\. Sampling Instrument Container

a\. Proper design, construction and repair for storing sample\
dipper in sanitizer

b\. Applicable test kit for checking strength of sanitizer (200 ppm\
chlorine or equivalent)

12\. Sample Containers

a\. Clean, properly sanitized or sterilized \
b. Adequate supply, properly stored or handled \
13. Sample Storage Case

a\. Rigid construction, suitable design to maintain samples at\
0°C - 4.4°C (32°F - 40°F), protected from contamination

b\. Ample space for refrigerant, racks provided as necessary

14\. Sample Collection -- Precautions and Procedures\
a. Sampling instrument and container(s) properly carried into and\
aseptically handled in milkhouse \
b. Bulk tank milk outlet valve sanitized before connecting transfer hose
\
c. Smell milk through tank port hole \
d. Observe milk in a quiescent state with lid wide open and lights\
on when necessary

e\. Test thermometer sanitized (1 min. contact time) \
f. Non-acceptable milk rejected \
g. Dry measuring stick with single-service paper towel \
h. Measure milk only when quiescent \
i. Do not contaminate milk during the measuring process \
j. Agitate milk before sampling at least 5 min. or longer as may be\
required by tank specifications

k\. Do not open bulk tank valve until milk is measured and sampled

l\. Temperature of milk, time, date of pickup and bulk milk
hauler/sampler\
name and license or permit no. recorded on each farm weight\
ticket recorded on each farm weight ticket

m\. Tank thermometer accuracy

1\. Tank thermometer accuracy checked monthly and recorded\
when used as test thermometer

2\. Accuracy of required recording thermometer checked monthly\
against standardized thermometer and recorded

n\. Temperature control sample provided at first sampling location\
for each rack of samples

o\. Temperature control sample properly labeled with time, date,\
temperature, producer ID and bulk milk hauler/sampler\
identification

p\. Sample containers legibly identified at collection points \
q. Sample dipper rinsed at least two times in the milk before\
transferring sample

r\. Dipper should be extended 6-8 inches into the milk to obtain\
representative sample

s\. Do not hold sample container over the milk when transferring\
sample into the container

t\. Fill sample container no more than ¾ full

u\. Rinse sample dipper in safe tap water, return to storage container,\
open tank valve, start milk transfer pump

v\. Immediately place milk sample in the sample case

15\. Sample Collection -- Storage and Transportation

a\. Sample storage -- refrigerant maintained no higher than milk level\
in sample containers -- maintain sample temperature -- do not\
bury tops of containers in ice, protect against contamination

b\. Deliver samples to laboratory promptly \
c. Samples and sample data -- submitted to laboratory -- if by\
common carrier, use tamper proof shipping case with top labeled\
"This Side Up"

+-----------------------+-----------------------+----------+-----------+
| REMARKS *(If          |                       |          |           |
| additional space is   |                       |          |           |
| required, please      |                       |          |           |
| place information on  |                       |          |           |
| the back of this Form |                       |          |           |
| or on a separate      |                       |          |           |
| page.)*               |                       |          |           |
|                       |                       |          |           |
|                       |                       |          |           |
+-----------------------+-----------------------+----------+-----------+
| DATE                  | SANITARIAN            | AGENCY   |           |
+-----------------------+-----------------------+----------+-----------+
|                       |                       |          |           |
+-----------------------+-----------------------+----------+-----------+
| **FORM FDA 2399a      |                       |          | PSC       |
| (10/06) FRONT         |                       |          | Graphics: |
| (PREVIOUS EDITIONS    |                       |          | (301)     |
| ARE OBSOLETE)**       |                       |          | 443-1090  |
|                       |                       |          | EF        |
+-----------------------+-----------------------+----------+-----------+

**BULK MILK HAULER/SAMPLER EVALUATION REPORT**

REMARKS *(Continued)*

  ---------------------------------------- ------------------------------
                                           

  **FORM FDA 2399a (10/06) BACK (PREVIOUS  
  EDITIONS ARE OBSOLETE)**                 
  ---------------------------------------- ------------------------------