Free 01242.FH11 - Indiana

APPLICATION FOR BULK MILK HAULER / SAMPLER PERMIT
State Form 1242 (R2 / 9-08)

Reset Form

INDIANA STATE BOARD OF ANIMAL HEALTH DAIRY DIVISION 805 Beachway Drive, Suite 50 Indianapolis, IN 46224 Telephone: (317) 227-0350 Fax number: (317) 227-0330

Pursuant to the provisions of IC 15-18-1-3, the following is an application form for a bulk milk hauler / sampler permit.
INSTRUCTIONS: 1. 2. 3. 4. Permit issued Please print clearly. Before the application can be considered, it must be filled out completely. If you do not make yourself available for inspection every two (2) years, the renewal permit will not be issued. Please complete this form and return it via fax or mail to the address above. Bulk hauler permit number

BH Please check one: Please check if applicable:

New
Name of applicant

Renewal

Field representative

In-line sampler approval requested

Address of applicant (number and street, city, state and ZIP code) Telephone number ( ) Cell phone number ( ) Fax number ( )

Grade of milk hauled
Name of milk route owner

Grade A

Manufacturing grade

Both

Address of milk route owner (number and street, city, state and ZIP code) Bulk Tank Unit (BTU) number(s) Route number(s)

Name of plant regularly haul to Location of plant County in which you pickup the majority of your stops

I hereby apply for a Bulk Milk Hauler / Sampler Permit. I agree to comply with Indiana Rules and Regulations concerning Bulk Milk Collection and Sampling Operations in performing as a bulk milk hauler in the State of Indiana. This is to affirm under penalty of perjury that the above facts are true.
Signature of applicant Date of signature (month, day, year)

This is to certify that the applicant has been thoroughly inspected and follows proper methods when collecting, sampling and grading bulk milk. I hereby approve this application and recommend that a permit be issued. Authorized signature required for new permits only.
Signature of authorized representative of the Board of Animal Health Date of signature (month, day, year)