Form 79-014 "Application and Permit to Obtain Specimens From Official Meat Inspection Establishment" - California

What Is Form 79-014?

This is a legal form that was released by the California Department of Food & Agriculture - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2011;
  • The latest edition provided by the California Department of Food & Agriculture;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form 79-014 by clicking the link below or browse more documents and templates provided by the California Department of Food & Agriculture.

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Download Form 79-014 "Application and Permit to Obtain Specimens From Official Meat Inspection Establishment" - California

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STATE OF CALIFORNIA
DEPARTMENT OF FOOD AND AGRICULTURE
Meat, Poultry and Egg Safety Branch
TO BE COMPLETED BY BRANCH CHIEF
1220 N Street
Sacramento, CA 95814
EXPIRES
PERMIT NUMBER
(916) 900-5004
79-014 (Rev. 08/11)
APPLICATION AND PERMIT TO OBTAIN SPECIMENS FROM OFFICIAL MEAT
INSPECTION ESTABLISHMENT
1. NAME AND ADDRESS OF ESTABLISHMENT WHERE
3. NAME AND ADDRESS OF INDIVIDUAL OR
SPECIMENS ARE TO BE OBTAINED:
ORGANIZATION:
2.
ESTABLISHMENT NO.:
4.
DATE OF REQUEST
5A.
The above applicant desires the following specimens not intended for human or animal food. The applicant agrees that the collecting and handling of this material shall be
at such time and place and in such manner as to not interfere with inspection or to cause any objectionable condition.
5B. KIND AND AMOUNT OF MATERIAL DESIRED:
6A. INDICATE PURPOSE OF COLLECTING SPECIMENS
EDUCATIONAL
RESEARCH
OTHER (Specify)
6B. DESCRIBE USE TO BE MADE OF THE SPECIMENS:
7. IF SPECIMENS ARE TO BE USED FOR "RESEARCH", (Item 6A ), THE FOLLOWING STATEMENT IS APPLICABLE:
"The applicant agrees to Use These Specimen(s) for Research Purposes Only and Assumes Full Responsibility for Results of Research
Involving These Specimens."
8.
CONSENT OF THE OFFICIAL ESTABLISHMENT HAS BEEN OBTAINED TO REMOVE SPECIMENS DESCRIBED IN ITEM 5B
9A.
TITLE OF APPLICANT:
9B.
SIGNATURE OF APPLICANT OR OFFICIAL OF ORGANIZATION
I declare under penalty of perjury that the information provided on this application is true and accurate to the best of
my knowledge.
TO BE COMPLETED BY THE BRANCH CHIEF
Permission is herewith given to applicant to obtain and remove specimens described in Item 5B.
10A.
SIGNATURE
10B. TITLE
10C. DATE
STATE OF CALIFORNIA
DEPARTMENT OF FOOD AND AGRICULTURE
Meat, Poultry and Egg Safety Branch
TO BE COMPLETED BY BRANCH CHIEF
1220 N Street
Sacramento, CA 95814
EXPIRES
PERMIT NUMBER
(916) 900-5004
79-014 (Rev. 08/11)
APPLICATION AND PERMIT TO OBTAIN SPECIMENS FROM OFFICIAL MEAT
INSPECTION ESTABLISHMENT
1. NAME AND ADDRESS OF ESTABLISHMENT WHERE
3. NAME AND ADDRESS OF INDIVIDUAL OR
SPECIMENS ARE TO BE OBTAINED:
ORGANIZATION:
2.
ESTABLISHMENT NO.:
4.
DATE OF REQUEST
5A.
The above applicant desires the following specimens not intended for human or animal food. The applicant agrees that the collecting and handling of this material shall be
at such time and place and in such manner as to not interfere with inspection or to cause any objectionable condition.
5B. KIND AND AMOUNT OF MATERIAL DESIRED:
6A. INDICATE PURPOSE OF COLLECTING SPECIMENS
EDUCATIONAL
RESEARCH
OTHER (Specify)
6B. DESCRIBE USE TO BE MADE OF THE SPECIMENS:
7. IF SPECIMENS ARE TO BE USED FOR "RESEARCH", (Item 6A ), THE FOLLOWING STATEMENT IS APPLICABLE:
"The applicant agrees to Use These Specimen(s) for Research Purposes Only and Assumes Full Responsibility for Results of Research
Involving These Specimens."
8.
CONSENT OF THE OFFICIAL ESTABLISHMENT HAS BEEN OBTAINED TO REMOVE SPECIMENS DESCRIBED IN ITEM 5B
9A.
TITLE OF APPLICANT:
9B.
SIGNATURE OF APPLICANT OR OFFICIAL OF ORGANIZATION
I declare under penalty of perjury that the information provided on this application is true and accurate to the best of
my knowledge.
TO BE COMPLETED BY THE BRANCH CHIEF
Permission is herewith given to applicant to obtain and remove specimens described in Item 5B.
10A.
SIGNATURE
10B. TITLE
10C. DATE