Form 79-006A Application to Operate a Collection Center - California

Form 79-006A is a California Department of Food & Agriculture form also known as the "Application To Operate A Collection Center". The latest edition of the form was released in August 1, 2018 and is available for digital filing.

Download a PDF version of the Form 79-006A down below or find it on California Department of Food & Agriculture Forms website.

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STATE+A1:BH53 OF CALIFORNIA
DEPARTMENT OF FOOD AND AGRICULTURE
Office Use Only
Establishment Number:
Meat, Poultry and Egg Safety Branch
Date:
1220 N Street
License Fee: $100.00
Sacramento, CA 95814
Enforcement Fee: $3,500.00 PLUS
(916) 900-5004
$500.00 per truck up to a maximum
79-006A (Rev. 08/18)
of $7,000.00 per plant per year
APPLICATION TO OPERATE A COLLECTION CENTER
In accordance with Article 2, Chapter 5, Part 3, Division 9, of the California Food and Agricultural Code, application
is hereby made for a license to operate as a Collection Center.
Inedible Kitchen Grease
Animal Material
Please Print or Type
(If more space is required, please use the back of this form)
Name of Business:
Phone Number:
FAX:
Mailing Address:
Location (if different):
City, State, Zipcode:
City, County, Zipcode:
Name of Contact Person:
Contact Person E-Mail Address:
Name and address of Owners or Corporate Officers and Managers
Name:
Name :
Address:
Address:
Name and Location of Renderer or Pet Food Processor through which denatured, inedible and/or condemned material
is to be disposed
Name:
Name:
Address:
Address:
Type of Business:
Type of Business:
Yes
No
Skinning, eviscerating, or cutting up carcasses will be conducted at this facility.
If yes, state the rendering facility where skinned material will be transported.
*Any change in the information contained in the license or registration application shall be reported in writing to the
Meat, Poultry and Egg Safety Branch within (10) business days of such change.
*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.
*Providing false information on applications for licenses or registration application shall be a violation and shall be
justification for denial of an application.
Printed Name of Applicant:
Signature of Applicant:
Mail application and fee to: Department of Food and Agriculture, 1220 N Street, Sacramento, CA 95814.
Please make check payable to: CDFA L 90101
STATE+A1:BH53 OF CALIFORNIA
DEPARTMENT OF FOOD AND AGRICULTURE
Office Use Only
Establishment Number:
Meat, Poultry and Egg Safety Branch
Date:
1220 N Street
License Fee: $100.00
Sacramento, CA 95814
Enforcement Fee: $3,500.00 PLUS
(916) 900-5004
$500.00 per truck up to a maximum
79-006A (Rev. 08/18)
of $7,000.00 per plant per year
APPLICATION TO OPERATE A COLLECTION CENTER
In accordance with Article 2, Chapter 5, Part 3, Division 9, of the California Food and Agricultural Code, application
is hereby made for a license to operate as a Collection Center.
Inedible Kitchen Grease
Animal Material
Please Print or Type
(If more space is required, please use the back of this form)
Name of Business:
Phone Number:
FAX:
Mailing Address:
Location (if different):
City, State, Zipcode:
City, County, Zipcode:
Name of Contact Person:
Contact Person E-Mail Address:
Name and address of Owners or Corporate Officers and Managers
Name:
Name :
Address:
Address:
Name and Location of Renderer or Pet Food Processor through which denatured, inedible and/or condemned material
is to be disposed
Name:
Name:
Address:
Address:
Type of Business:
Type of Business:
Yes
No
Skinning, eviscerating, or cutting up carcasses will be conducted at this facility.
If yes, state the rendering facility where skinned material will be transported.
*Any change in the information contained in the license or registration application shall be reported in writing to the
Meat, Poultry and Egg Safety Branch within (10) business days of such change.
*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.
*Providing false information on applications for licenses or registration application shall be a violation and shall be
justification for denial of an application.
Printed Name of Applicant:
Signature of Applicant:
Mail application and fee to: Department of Food and Agriculture, 1220 N Street, Sacramento, CA 95814.
Please make check payable to: CDFA L 90101

Download Form 79-006A Application to Operate a Collection Center - California

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