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( Shellfish Harvest Record | Shellfish Harvest / Purchase Record | Shellfish Sales Record | Export Health Certificate )
Company Name: _________________________________________________
Certificate No: ___________________________________________________
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Harvest Area |
Harvest Date |
Species |
Quantity |
|---|---|---|---|
Page ______
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Cert. No. |
Quantity |
Species |
Harvest Area |
Harvest Date |
Purchase Date |
Harvester Cert. # |
|---|---|---|---|---|---|---|
Page________
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Date Sold |
Sold To |
Quantity |
Species |
Harvest Date |
Harvest Area |
Harvester Cert. # |
|---|---|---|---|---|---|---|
Page ___________
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STATE OF _______________________________________________ ADDRESS _______________________________________________ |
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STATEMENT OF LICENSURE AND CERTIFICATION Exported By: Certificate # ______________ Consigned To: |
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| License (Check one): | ||||
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Shipped Via: |
Port of Embarkation: |
Port of Debarkation: |
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Identifying Marks: |
Total # of Containers: |
Total Marked Weight: |
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Product: |
Class, Type, Style: |
Count: |
Lot Weight: |
Labels/Brand: |
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The above-named exporter hereby certifies through its authorized agent that this product was harvested from the following harvest area or areas: |
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Agent's Signature: _______________________________ Date: __________________ |
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The __________________ State Department of Health routinely inspects shellfish operations and shellfish harvest areas to determine their compliance with state shellfish sanitation laws and the requirements of the National Shellfish Sanitation Program. The above named exporter is currently licensed and certified by the Department as indicated above. The above named harvest area is currently certified by the Department of Health as approved for harvest. By:____________________________________ Date:_______________________ (Appropriate state official/title) |
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