Form 79-003A Application to Operate a Poultry Plant - California

Form 79-003A is a California Department of Food & Agriculture form also known as the "Application To Operate A Poultry Plant". The latest edition of the form was released in January 1, 2013 and is available for digital filing.

Download a PDF version of the Form 79-003A down below or find it on California Department of Food & Agriculture Forms website.

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STATE OF CALIFORNIA
DEPARTMENT OF FOOD AND AGRICULTURE
Meat, Poultry and Egg Safety Branch
Distribution:
1220 N Street
1 - Headquarters
Sacramento, CA 95814
2 - Inspector
3 - Area Supervisor
(916) 900-5004
79-003A (Rev. 01/13)
Date:
APPLICATION TO OPERATE A
POULTRY PLANT
FEE $500.00
Establishment Number:
Please Print or Type:
Name of Business:
Phone Number:
Mailing Address:
Fax Number:
Location Including County:
Name of Owners, Managers, and Partners:
Name of Contact Person:
Contact Person E-mail Address:
Name of Poultry Meat Inspectors (PMIs) Employed (Including Managers, Owners, if Licensed):
Any changes in the information given must be reported to the Meat, Poultry and Egg Safety Branch within 15 days.
Obtaining all information requested is mandatory and required before a license can be issued according to
requirements in Division 9 of the California Food and Agricultural Code.
Mail application and Five Hundred dollar ($500.00) fee to:
Cashier, Department of Food and Agriculture,
1220 N Street, Sacramento, CA 95814. Please make check payable to: CDFA PL 90316
Printed Name of Applicant:
Signature of Applicant:
STATE OF CALIFORNIA
DEPARTMENT OF FOOD AND AGRICULTURE
Meat, Poultry and Egg Safety Branch
Distribution:
1220 N Street
1 - Headquarters
Sacramento, CA 95814
2 - Inspector
3 - Area Supervisor
(916) 900-5004
79-003A (Rev. 01/13)
Date:
APPLICATION TO OPERATE A
POULTRY PLANT
FEE $500.00
Establishment Number:
Please Print or Type:
Name of Business:
Phone Number:
Mailing Address:
Fax Number:
Location Including County:
Name of Owners, Managers, and Partners:
Name of Contact Person:
Contact Person E-mail Address:
Name of Poultry Meat Inspectors (PMIs) Employed (Including Managers, Owners, if Licensed):
Any changes in the information given must be reported to the Meat, Poultry and Egg Safety Branch within 15 days.
Obtaining all information requested is mandatory and required before a license can be issued according to
requirements in Division 9 of the California Food and Agricultural Code.
Mail application and Five Hundred dollar ($500.00) fee to:
Cashier, Department of Food and Agriculture,
1220 N Street, Sacramento, CA 95814. Please make check payable to: CDFA PL 90316
Printed Name of Applicant:
Signature of Applicant:

Download Form 79-003A Application to Operate a Poultry Plant - California

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