Form FDA Form 3038 FDA Form 3038 Interstate Shellfish Dealer's Certificate

DEPARTMENT OF HEALTH AND HUMAN SERVICES

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FOOD AND DRUG ADMINISTRATION
(See Reverse of Part III tor Instructions)

SECTION 1- COMPLETED
1. SHELLFISH DEALER / SHIPPER (Name)

(Check One)

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Certification
Cancellation

Form Approved: OMB No. 0910-0021
Expiration Date: March 31,2013
See Burden Statement on back of Part III.

Change
Renewal

BY STATE SHELLFISH CONTROL AUTHORITY
2.

CERTIFICATION

a) CERTIFICATE NUMBER

b) DATE CERTIFIED

c) STATE

d) EXPIRATION DATE

FACILITY ADDRESS (Include Street No., City, State, & ZIP)

MAILING ADDRESS (If different than above)

e) CATEGORY SYMBOL

TELEPHONE

(

)

3 DATE OF ON-SITE INSPECTION

6. CANCELLATION DATE

LL~

DP - Depuration

RP - Repacker

RS - Reshipper

SP - Shucker-Packer
AQ - Aquaculture

55 - Shell Stock Shipper
WS - Wet Storage

PHP - Post Harvest
Processor

5. EXPIRATION DATE OF INSPECTOR'S

4. STATE SHELLFISH STANDARDIZATION INSPECTOR (Print
Name)

STANDARDIZATION

7. REASON FOR CANCELLATION (Check One)

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8. a) STATE SHELLFISH CONTROL AUTHORITY
DESIGNEE (Print Name)

SECTiON

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Decertification

Out of Business

Other (Please Specify)
c) DATE CERTIFICATE SENT TO FDA

b) SIGNATURE

II - COMPLETED BY DIVISION OF COOPERATIVE PROGRAMS ­ FDA

9. DATE CERTIFICATE RECEIVED

10. DATE CERTIFICATE PUBLISHED

THIS CERTIFICATE MUST BE KEPT ON FILE FOR A PERIOD OF TWO (2) YEARS.
FORM FDA 3038 (7/10)
(Replaces Forms FDA 3038b and FDA 3038c which are obsolete.)

PART

1 • HFS-625

INTERSTATE SHELLFISH
DEALER'S CERTIFICATE
psc Graphic,.- (301) 443-1090

EF