Animal Services DivisionPO Box 42577Olympia WA 98504-2577(360) 902-1878 APPLICATION FOR APPROVAL

TO REMOVE INEDIBLE OR CONDEMNED DENATURED MATERIAL FROM ESTABLISHMENT

DATE ISSUEDVALID UNTIL REVOKED

Firm Name: .............................................................................................................................................. Establishment No. ...............................................

Address: ..................................................................................................................................................................................................................................

I hereby apply for approval to remove inedible and/or condemned denatured and/or decharacterized material described below from my establishment.

1. Type of material to be removed (describe fully): .........................................................................................................................................................

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2. Intended use of such material: ....................................................................................................................................................................................

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3. Material denatured or decharacterized by (describe method and chemical used, see list below): .............................................................................

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4.Nameandaddressoffirmorindividualtowhomreleased:

Firm #1 Name: .............................................................................................................................................................................................................

Firm #1 Address: .........................................................................................................................................................................................................

Material for Firm #1: ....................................................................................................................................................................................................

Firm #2 Name: .............................................................................................................................................................................................................

Firm #2 Address: .........................................................................................................................................................................................................

Material for Firm #2: ....................................................................................................................................................................................................It is understood that approval of this application in no way acknowledges liability of the state of Washington for any damages which might result from the use of materials approved for release by the Washington State Department of Agriculture.

Authorized Signature: ..............................................................................................................................................................................................................

Title: ...................................................................................................................................................................... Date: ......................................................

AGR FORM 401-3014 (R/12/13)

ACCEPTED DENATURANTS AND DECHARACTERIZINGOffaltobeusedforanimalfeed,suchasslashedlungs,spleens,flukylivers,liverswithabscessestrimmedout,etc.,whichhavebeenapproved for release as animal feed must be decharacterized bytheuseofsufficientquantitiesofvariousapprovedagentstorenderthemunfitforpossiblehumanconsumption. DECHARACTERIZING AGENT Meats: FD&C #3 Green Dye Finely Powdered Charcoal Berkoline “B” (Birko Chemical Corporation) Berkoline “G” (Birko Chemical Corporation) Politol-S (Westvaco Chemical Division) Poultry: Ultramarine Blue Dye FD&C #3 Green Dye FD&C #2 Red Dye FD&C #3 Red Dye FD&C #1 Blue Dye FD&C #2 Blue Dye

Condemnedmaterialswhichmaynotbereleasedforanypurposebuttogototherenderingworks,orotherfacilities,forfinaldestruc-tion must be denatured as listed below: DENATURING AGENT Meat Carcasses: Crude Carbolic Acid Cresylic Disinfectant FD&C #3 Green Dye with Citronella and Detergent Poultry Carcasses: Crude Carbolic Acid Kerosene, Fuel Oil or Crankcase Oil Phenolic Disinfectant

WSDA USE ONLY

State Veterinarian: ............................................................................................................................... Date: ...................................................................