to Creamery at.......... Formerly at.........
5 Operated by.................. Address.......................
6 Distance of farm from Creamery..... Occupied farm since.....
7 No. Cows....... No. Milking...... No. Qts. Produced.........
8 All persons in the households of those engaged in producing
or handling milk are............free from all infectious
disease. Weekly reports are..................being filed
..........................................................
9 Date and nature of last case on farm........................
10 =WATER SUPPLY= for utensils is from a............... located
.......... feet deep and apparently is............ pure and
wholesome............ State any possible contamination
located within 200 feet of source of water supply or
if water supply is not protected against surface drainage
...........................................................
...........................................................
11 Water supply on this farm analyzed.... 191.. Result........
12 Style of Cow Barn.... Length.... ft. Width.... ft. Height
of ceiling.... ft.
13 =Dairy Rules= of the Department of Health are........ posted
..................
14 =Dairy Herd= examined by............. on.............. 191..
Report............

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|Perfect| Allow |
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EQUIPMENT | | |
| | |
15 =COW STABLE= is.......located on elevated | | |
ground with no stagnant water, hog-pen, | | |
privy, uncovered cesspool or manure pit | | |
within 100 feet | 1 | ..... |
| | |
16 =FLOORS=, other than cow beds, are | | |
of concrete or some non-absorbent material | 2 | ..... |
| | |
17 Floors are...properly graded and water-tight | 2 | ..... |
| | |
18 =Cow beds are=...of concrete or planks | |