DA-157 Request to Validate Prior Meat & PY Equipment Acceptance

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Form Approved OMB No. 0581-0126

U. S. DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE
DAIRY PROGRAMS

REQUEST TO VALIDATE A PRIOR MEAT AND POULTRY EQUIPMENT ACCEPTANCE
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a
collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is
0581-NEW. The time required to complete this information collection is estimated to average 3 minutes per response, including the time
for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the
collection of information.
The U.S. Department of Agriculture (USDA) prohibits discrimination in all of its programs and activities on the basis of race, color,
national origin, age, disability, and where applicable, sex (including gender identity and expression), marital status, familial status,
parental status, religion, sexual orientation, political beliefs, genetic information, reprisal, or because all or part of an individual's
income is derived from any public assistance program. (Not all prohibited bases apply to all programs.) Persons with disabilities who
require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA's TARGET
Center at (202) 720-2600 (voice and TDD).
To file a complaint of discrimination, write to USDA, Director, Office of Civil Rights, 1400 Independence Avenue, S.W., Washington, D.C.
20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.
Application is hereby made, in accordance with the provisions of the appropriate sections of the Regulations Governing the Inspection and
Grading of Manufactured or Processed Dairy Products (7 CFR, Ch. I, Part 58, Subpart A), or the Regulations Governing the Certification of
Sanitary Design and Fabrication of Equipment Used in the Slaughter, Processing, and Packaging of Livestock and Poultry Products (7 CFR,
Ch. I, Part 54, Subpart C), for validation of a prior meat and poultry equipment acceptance. The applicant (listed below) certifies to the
statements made below and affirms compliance to the aforesaid regulations and such instructions as may be issued by the Administrator,
Agricultural Marketing Service covering evaluation and certification of equipment or utensils by the Dairy Programs.
Name and Address of Applicant:

Equipment or Utensil:

E-mail Address:
Telephone No:

Project Number:

Fax No:

Date of Prior Acceptance:
I certify that the design, materials of construction, and fabrication of the above referenced equipment or utensil
has not been modified, changed, or revised and remains the same as previously reviewed and accepted by the Dairy
Grading Branch.
I certify that the design, materials of construction, or fabrication of the above referenced equipment or utensil
has been modified and that all modifications, changes, or revisions to the design, materials of construction, or fabrication
are submitted for evaluation in the attached engineering drawings or listing of materials. I further acknowledge that if
the submitted information is not evaluated before the expiration date of my equipment or utensil that the accepted
listing will be deleted until completion of the evaluation.
I request that our listing for acceptance of the above referenced equipment or utensil be deleted.

Signature of Applicant President/CEO:

Signature of Applicant Director of Engineering:

Dairy Grading Branch Concurrence:

Date:

Date:

Form DA-157 (06-2012)

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