1900 Hendon Avenue St



Please fill out this questionnaire if you are requesting organic handling certification. Attach a Multi-Ingredient Product Profile sheet and label for each product requested for organic certification or re-certification, and a current schematic product flow chart and facility map for each facility which will handle organic products. Use additional sheets if necessary.SECTION 1: General InformationNOP Rule §205.401Applicant (Name/Company): FORMTEXT ?????FOR OFFICE USE ONLYCheck #: Applicant No.: FORMTEXT ?????Owner/Manager: FORMTEXT ?????Primary Contact Person: FORMTEXT ?????Organic Supervisor: FORMTEXT ?????Amount: Pegboard #: Initials: Address: FORMTEXT ?????Late Fees: Other: City: FORMTEXT ?????State: FORMTEXT ?????Zip Code: FORMTEXT ?????Phone: FORMTEXT ?????Fax: FORMTEXT ?????Cell: FORMTEXT ?????E-mail: FORMTEXT ?????Legal Status: FORMCHECKBOX Corporation FORMCHECKBOX Legal partnership (Federal Form 1065) FORMCHECKBOX Sole proprietorship FORMCHECKBOX Trust or Non-profit FORMCHECKBOX Other (specify): FORMTEXT ?????Year CompanyBegan: FORMTEXT ?????Number ofEmployees: FORMTEXT ?????Government Permits/Licenses: FORMTEXT ?????What type(s) of organic products are or will be handled? Provide a complete list of products requested for certification in Section 6: Product Composition and Labeling. FORMTEXT ?????Describe activities you wish to perform on organic products (such as processing, packaging, labeling, etc.): FORMTEXT ?????Year first certified organic: FORMTEXT ?????List previous organic certification: FORMTEXT ?????List current organic certification: FORMTEXT ?????Has certification ever been denied, suspended, or revoked? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, describe the circumstance and attach documentation: FORMTEXT ?????List all noncompliance issues from last year's certification contract and state how they have been addressed. FORMCHECKBOX Not applicable FORMTEXT ?????Do you have access to a current copy of MCIA’s Organic Handbook? FORMCHECKBOX Yes FORMCHECKBOX NoDo you have access to a current copy of the NOP Standards? FORMCHECKBOX Yes FORMCHECKBOX NoPreferred time for inspection: FORMCHECKBOX AM FORMCHECKBOX PMGive directions to the processing facility: FORMTEXT ?????Does your company plan to custom produce, process, label, or store organic products for another company? FORMCHECKBOX Yes FORMCHECKBOX No If yes, please complete the table below. Company name Product name (exactly as appears on label)Is contracting company certified organic?Identify certifier on label FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????List or attach a list of all nonorganic products produced by your company. FORMTEXT ?????SECTION 2: Assurance of Organic IntegrityNOP Rule §205.272NOP Rule requires that handling procedures, processes, storage, and equipment present no contamination risk to organic products from commingling with nonorganic products or contamination with prohibited substances. Packaging materials, bins, and storage containers must not have contained synthetic fungicides, preservatives, or fumigants. Reusable bags or containers must be clean and pose no risk to the integrity of organic products. Procedures used to maintain organic integrity must be ANIC CONTROL POINTSSimilar to Hazard Analysis Critical Control Points (HACCP), Organic Control Points (OCPs) are points in a production or handling system where the integrity of the organic product may be compromised. Examples are improper cleaning of a piece of equipment prior to running organic product, resulting in commingling with nonorganic products left in the equipment, or use of a prohibited pesticide when organic product is present, resulting in contamination by a prohibited substance.Do you have an Organic Control Point program in place to address areas of potential commingling and/or contamination? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, list Organic Control Points you have identified in your process and state how you have addressed them to protect organic integrity, or attach a copy of your Organic Control Point program. FORMTEXT ?????If no, do you have plans to implement an Organic Control Point program? FORMCHECKBOX Yes FORMCHECKBOX NoDo you use an Organic Quality Control Manual? FORMCHECKBOX Yes FORMCHECKBOX NoIndicate how you assure employees are trained in organic handling protocols: FORMTEXT ?????Is documentation of training maintained? FORMCHECKBOX Yes FORMCHECKBOX NoMONITORING Do you have a Quality Assurance program in place? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, what program do you use? FORMCHECKBOX ISO FORMCHECKBOX HACCP FORMCHECKBOX TQM FORMCHECKBOX Other (specify): FORMTEXT ?????Are any outside quality assessment services used (e.g., AIB)? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, name of company: FORMTEXT ?????Product testing: (Check all that apply) FORMCHECKBOX Ingredients tested prior to purchase FORMCHECKBOX Ingredients tested upon receipt FORMCHECKBOX Products tested during production FORMCHECKBOX Finished products tested FORMCHECKBOX Other (specify): FORMTEXT ?????List type of testing: FORMTEXT ?????How do you prevent the use of ingredients produced using excluded methods (genetic engineering), sewage sludge, or ionizing radiation? (Check all that apply) FORMCHECKBOX GE testing FORMCHECKBOX Letters from manufacturers FORMCHECKBOX Organic Certificates FORMCHECKBOX Transaction Certificates FORMCHECKBOX Other (specify): FORMTEXT ?????Are ingredient samples retained? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, how long? FORMTEXT ????? Are finished product samples retained? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, how long? FORMTEXT ?????Do you have a product recall system in place? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, describe your product recall system. FORMTEXT ?????SECTION 3: Pest ManagementNOP Rule §205.271NOP Rule requires management practices to prevent pests, such as removal of pest habitat, food sources, and breeding areas, and prevention of access to handing facilities. Environmental factors, such as temperature, light, humidity, atmosphere, and air circulation, may be used to prevent pests. Pests may be controlled using mechanical or physical means, such as traps, light, or sound. Lures and repellents may be used if they do not contain prohibited substances or products produced using excluded methods (genetic engineered). If these measures are not effective, a prohibited synthetic substance not on the National List may be used provided the certifying agent approves of the substance, method of application, and measures taken to prevent contact with ingredients or organic products. Use of pest control products must be documented and included as part of the Organic Handling Plan.Attach a facility map showing the location of traps and monitors, and SDS and/or label information for substances used for pest control, if applicable.What type of pest management system do you use? FORMCHECKBOX In-house: Name of responsible person FORMTEXT ????? FORMCHECKBOX Contract pest control service: Name, address, and phone number FORMTEXT ?????Check all pest problems you generally have: FORMCHECKBOX Birds FORMCHECKBOX Crawling insects FORMCHECKBOX Flying insects FORMCHECKBOX Mice FORMCHECKBOX Rats FORMCHECKBOX Spiders FORMCHECKBOX Other (specify) FORMTEXT ?????Check all pest management practices you use: FORMCHECKBOX Air curtains FORMCHECKBOX Air showers FORMCHECKBOX Boric acid FORMCHECKBOX Carbon dioxide FORMCHECKBOX Cleanup of spilled product FORMCHECKBOX Crack and crevice spray FORMCHECKBOX Diatomaceous earth FORMCHECKBOX Disodium octaltetrahydrate FORMCHECKBOX Electrocutors FORMCHECKBOX Exclusion FORMCHECKBOX Fogging FORMCHECKBOX Freezing treatments FORMCHECKBOX Fumigation FORMCHECKBOX Good sanitation FORMCHECKBOX Heat treatments FORMCHECKBOX Incoming ingredientinspection for pests FORMCHECKBOX Inspection zones around FORMCHECKBOX Mechanical traps FORMCHECKBOX Monitoring FORMCHECKBOX Mowinginterior perimeter FORMCHECKBOX Nitrogen FORMCHECKBOX Pheromone traps FORMCHECKBOX Physical barriers FORMCHECKBOX Positive air pressurein facility FORMCHECKBOX Precipitated silica FORMCHECKBOX Pyrethrum FORMCHECKBOX Release of beneficials FORMCHECKBOX Removal of exteriorhabitat/food sources FORMCHECKBOX Repair of holes, cracks, FORMCHECKBOX Rotenone FORMCHECKBOX Ryania FORMCHECKBOX Scare eye balloons etc. FORMCHECKBOX Screened windows, vents, FORMCHECKBOX Sealed doors and/or FORMCHECKBOX Sheet metal on sides FORMCHECKBOX Sticky trapsetc.windowsof building exterior FORMCHECKBOX Ultrasound/light devices FORMCHECKBOX Vacuum treatments FORMCHECKBOX Vitamin baits FORMCHECKBOX Other (specify) FORMTEXT ?????Are records kept of your monitoring activities? FORMCHECKBOX Yes FORMCHECKBOX NoCheck all aspects of your waste management system that apply: FORMCHECKBOX Composting FORMCHECKBOX Daily pick-up of waste FORMCHECKBOX Field application of waste FORMCHECKBOX Material recycling FORMCHECKBOX On-site dumpster FORMCHECKBOX Other (specify) FORMTEXT ?????Does your waste management system provide habitat and/or food sources for pests? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, please describe. FORMTEXT ?????Pesticide use information for the last 12 months:SubstanceTarget pestLocation where usedMethod of applicationDate of last application FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Are any substances used which are prohibited according to the National List? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, did you contact the certifying agent for prior approval before using? FORMCHECKBOX Yes FORMCHECKBOX NoAre records kept of all pesticide applications? FORMCHECKBOX Yes FORMCHECKBOX NoIf prohibited pest control substances were used, list all measures taken to prevent contact with organic products or ingredients. FORMTEXT ?????If prohibited pest control products were used, what measures are you taking or planning to take to prevent their use in the future? FORMTEXT ?????Are there any substances intended for use that are not listed above? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, list substances intended for use: FORMTEXT ?????SECTION 4: Water UseNOP Rule §205.270WATER Check ways water is used in processing: FORMCHECKBOX None used FORMCHECKBOX Cleaning equipment FORMCHECKBOX Cleaning organic product FORMCHECKBOX Cooking FORMCHECKBOX Cooling FORMCHECKBOX Ingredient FORMCHECKBOX Processing aid FORMCHECKBOX Product transport FORMCHECKBOX Other (specify) FORMTEXT ?????Source of water: FORMCHECKBOX Municipal FORMCHECKBOX On-site well FORMCHECKBOX Other (specify) FORMTEXT ?????Does the water meet the Safe Drinking Water Act? FORMCHECKBOX Yes FORMCHECKBOX NoAttach copy of water test, if applicable. List any known water contaminants: FORMCHECKBOX None FORMTEXT ????? What on-site water treatment processes are used? FORMCHECKBOX None FORMTEXT ?????Describe cleaning and maintenance of water treatment facilities: FORMTEXT ?????Do you use water conservation strategies? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, describe your water conservation program: FORMTEXT ?????Describe how you monitor water quality: FORMTEXT ?????How often do you conduct water quality monitoring? FORMCHECKBOX Weekly FORMCHECKBOX Monthly FORMCHECKBOX Annually FORMCHECKBOX Other: FORMTEXT ?????STEAMIs steam used in the processing of organic products? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, describe how steam is used in the manufacturing process: FORMTEXT ?????If steam has direct contact with organic products, do you use: FORMCHECKBOX No direct contact FORMCHECKBOX Condensate traps FORMCHECKBOX Steam filters FORMCHECKBOX Testing of condensate FORMCHECKBOX Testing of finished products FORMCHECKBOX Other (specify) FORMTEXT ?????List products used as boiler additives: FORMCHECKBOX No boiler additives used FORMTEXT ?????Attach MSDA and/or label information for boiler additives, if applicable.SECTION 5: Record KeepingNOP Rule §205.103NOP Rule requires that records disclose all activities and transactions of the operation, be maintained for 5 years, and demonstrate compliance with the NOP Rule. Organic products must be tracked from incoming ingredients to sale of finished product. Organic ingredients must be verified as certified organic. Amounts of organic finished products must balance with certified organic ingredients purchased. All relevant documents must identify products as "organic." All records must be accessible to the inspector.Can your record keeping system track the finished product back to all ingredients? FORMCHECKBOX Yes FORMCHECKBOX NoCan your record keeping system balance organic ingredients in to organic products out? FORMCHECKBOX Yes FORMCHECKBOX NoHow long do you keep your records? FORMTEXT ?????How do you record complaints regarding the organic status of your product? FORMTEXT ?????Which of the following records do you keep for organic processing/handling?INCOMING: FORMCHECKBOX Bills of lading FORMCHECKBOX Certificates of analysis FORMCHECKBOX Contracts FORMCHECKBOX Copies of Certificates ofOrganic Operation FORMCHECKBOX Customs forms FORMCHECKBOX Documentation of commercial availability of organic FORMCHECKBOX Invoicesingredients when using nonorganic ingredients for products labeled as “100% organic” and/or “organic” FORMCHECKBOX Purchase orders FORMCHECKBOX Quality test results FORMCHECKBOX Receipts FORMCHECKBOX Receiving records FORMCHECKBOX Receiving summary log FORMCHECKBOX Scale tickets FORMCHECKBOX Transaction certificates FORMCHECKBOX Verification of ingredients(12 months)produced not usingsewage sludge FORMCHECKBOX Verification of ingredients FORMCHECKBOX Verification of non-GMO FORMCHECKBOX Other (specify): FORMTEXT ?????produced/handled withoutingredientsionizing radiationIN-PROCESS: FORMCHECKBOX Blending reports FORMCHECKBOX Equipment clean-out FORMCHECKBOX Finished product FORMCHECKBOX Ingredient inspectionlogsinventory reportsforms FORMCHECKBOX Ingredient inventory FORMCHECKBOX Packaging reports FORMCHECKBOX Production reports FORMCHECKBOX Production summaryreportsrecords (12 months) FORMCHECKBOX QA reports FORMCHECKBOX Sanitation logs FORMCHECKBOX Other (specify): FORMTEXT ?????OUTGOING: FORMCHECKBOX Audit control register FORMCHECKBOX Bills of lading FORMCHECKBOX Complaint log FORMCHECKBOX Copies of Certificates of Organic Operation FORMCHECKBOX Export declaration forms FORMCHECKBOX Phytosanitary certificates FORMCHECKBOX Purchase orders FORMCHECKBOX Sales orders FORMCHECKBOX Sales summary log FORMCHECKBOX Scale tickets FORMCHECKBOX Shipping log FORMCHECKBOX Shipping summary log FORMCHECKBOX Transaction certificates FORMCHECKBOX Transport unit inspection/ FORMCHECKBOX Other (specify): FORMTEXT ?????cleaning formsDescribe your lot numbering system. FORMTEXT ?????SECTION 6: Labeling and Product CompositionNOP Rule §205.105, 205.270, 205.300–205.305 and 205.307–205.311The NOP Rule has four categories of products allowed to use the word “organic.” These are “100% organic,” “organic,” “made with organic (specified ingredients or food group(s)),” and products with less than 70% organic ingredients. The percentage of organic ingredients is calculated by dividing the total net weight or volume (excluding salt and water) of combined organic ingredients by the total weight or volume of all ingredients.Products labeled “100% organic” must contain 100% organic ingredients, including processing aids. Products labeled “organic” must contain at least 95% organic ingredients; nonorganic ingredients must not be commercially available in an organic form; must not include organic and nonorganic forms of the same ingredient; and all ingredients and processing aids must be certified organic or be on the National List. Products labeled “made with organic (specified ingredients or food group(s))” must contain at least 70% organic ingredients. For “100% organic,” “organic,” and “made with organic . . .” products, both organic and nonorganic ingredients must not be produced using excluded methods, sewage sludge, or ionizing radiation. Products with less than 70% organic ingredients can only identify the organic ingredients in the information panel. Refer to the National List, Section 205.605 and 205.606, to determine which nonagricultural substances and nonorganically produced agricultural ingredients are allowed in products labeled “organic” or “made with organic (ingredients or food group(s)).”The NOP Rule has specific requirements for principal display panel information relating to the use of the term “organic,” depending on the percentage of organic ingredients in the finished product. For all products, the organic ingredients must be identified in the ingredient information panel. Up to three ingredients or food groups can be listed on the principal display panel for products labeled as “made with organic (ingredients or food group(s)).” The term “organic” cannot be used to describe a nonorganic ingredient in a product name. Water and salt cannot be identified as “organic.” The name of the certifying agent must be identified on the information panel below the name of the handler or distributor, preceded by the statement, “Certified organic by . . .” or similar phrase. The address and telephone number of the certifying agent may be displayed.The USDA seal can be used on “100% organic” or “organic” products, but not on products labeled “made with organic. . . .” A certifying agent’s seal, logo, or other identifying mark can be used on “100% organic,” “organic,” or “made with organic. . . .” Products with less than 70% organic ingredients cannot use the USDA seal or the certifying agent’s name, seal, or logo. The certifying agent’s seal cannot be displayed more prominently than the USDA seal. NOTE: List or attach an Organic Product list for all single ingredient products, a Multi-Ingredient Product Profile sheet for each multiple ingredient product, and a copy of all labels used for each product requested for certification, listed in Sections 6A through 6E.PRODUCTS LABELED AS “100% ORGANIC” (all ingredients are certified organic, including processing aids)List all products labeled or planned to be labeled as “100% Organic” and check appropriate boxes. FORMCHECKBOX NoneName of productOrganic ingredients identified on information panelMCIA identified on labelUSDA sealMCIA logo FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Products labeled as “Organic” (at least 95% certified organic ingredients)List all products labeled or planned to be labeled as “Organic” and check appropriate boxes. FORMCHECKBOX NoneName of productOrganic ingredients identified on information panel MCIA identified on labelUSDA seal MCIA logo FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Products labeled as “Made with Organic (specified ingredients or food groups(s)” (at least 70% certified organic ingredients; up to 3 ingredients or food groups can be listed)List all products to be labeled “Made with organic (ingredients or food group(s))” and check appropriate boxes. FORMCHECKBOX NoneName of productHow many ingredients/food groups are listed on the label?List each ingredient/food group on the principal display panelOrganic ingredients identified on information panelMCIA identified on labelMCIA logo FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Does the size of the percentage statement exceed one-half the size of the largest type size onthe panel on which the statement is displayed? FORMCHECKBOX Yes FORMCHECKBOX NoDoes the percentage statement appear in its entirety in the same type size, style, and color without highlighting? FORMCHECKBOX Yes FORMCHECKBOX NoPRODUCTS WITH LESS THAN 70% ORGANIC INGREDIENTS (organic ingredients listed only on the information panel) List all products which contain less than 70% organic ingredients. FORMCHECKBOX None FORMTEXT ?????WASTE PRODUCTSWill any wastes from certified organic products be sold as certified organic? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, list all organic products manufactured from waste materials. FORMTEXT ?????SECTION 7: Organic Handling RequirementsNOP Rule §205.270A.PRODUCT FLOWAttach a complete written description or schematic product flow chart that shows the movement of all organic products, from incoming/receiving through production to outgoing/shipping. Indicate where ingredients are added and/or processing aids are used. All equipment and storage areas must be identified.B.EQUIPMENT List all equipment used in processing.Equipment NameCapacityCheck if equipment is cleaned prior to organic production Check if cleaning is documentedCheck if the equipment is purged prior to organic production FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX If equipment is purged, list and describe purge procedures, quantities purged, and documentation. C.SANITATIONAttach SDS and/or label information for cleaning and sanitizing products, if applicable.Check all cleaning methods used: FORMCHECKBOX Clean in place (CIP) FORMCHECKBOX Compressed air FORMCHECKBOX Manual washing FORMCHECKBOX Sanitizing FORMCHECKBOX Scraping FORMCHECKBOX Steam cleaning FORMCHECKBOX Sweeping FORMCHECKBOX Vacuuming FORMCHECKBOX Other (specify): FORMTEXT ?????Provide information on your cleaning program and products used.AreaType of cleaningCleaning equipment used Products usedFreqCheck if cleaning is documentedReceiving area FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Ingredient storage FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Product transfer FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Production area FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Production equipment FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Packaging area FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Finished product storage FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Loading dock FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Building exterior FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Accidental spills FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Other (specify) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Are all surfaces which contact organic products food grade? FORMCHECKBOX Yes FORMCHECKBOX NoDo you test food contact surfaces or rinsate for cleaner/sanitizer residues? FORMCHECKBOX Yes FORMCHECKBOX NoWhere are cleaning/sanitizing materials stored? FORMTEXT ?????D.PACKAGINGCheck types of packaging material used: FORMCHECKBOX Aseptic FORMCHECKBOX Bulk FORMCHECKBOX Cardboard FORMCHECKBOX Foil FORMCHECKBOX Glass FORMCHECKBOX Metal FORMCHECKBOX Natural fiber FORMCHECKBOX Paper FORMCHECKBOX Plastic FORMCHECKBOX Synthetic fiber FORMCHECKBOX Waxed paper FORMCHECKBOX Wood FORMCHECKBOX Other (specify): FORMTEXT ?????Are all packaging materials food grade? FORMCHECKBOX Yes FORMCHECKBOX NoWhere are packaging materials stored? FORMTEXT ?????Are any fungicides, fumigants, or pest control products used in this storage area? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, describe use and products. FORMTEXT ?????Have any packaging materials been exposed to synthetic fungicides, preservatives, or fumigants? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, describe exposure, including name of products used. FORMTEXT ?????Are packaging materials reused? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, describe how reusable packaging materials are cleaned prior to use. FORMTEXT ?????Are reusable packaging materials used for both organic and nonorganic products? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, list specific nonorganic products packaged. FORMTEXT ?????E.STORAGEProvide information on your storage areas by completing the following table.UseLocationType/capacityIdentification name or numberCheck if storage unit is dedicated organicComments on potential for contamination or commingling problemsIngredient storage FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????Packaging material storage FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????In-process storage FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????Finished product storage FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????Off-site storage* FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????Other (specify) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????*If there is off-site storage, give name, address, phone number, contact person, and type of products stored at off-site facility: FORMTEXT ?????F.TRANSPORTATION OF ORGANIC PRODUCTSINCOMING:In what forms are incoming products received? FORMCHECKBOX Cardboard drums FORMCHECKBOX Dry bulk FORMCHECKBOX Foil bags FORMCHECKBOX Liquid bulk FORMCHECKBOX Metal drums FORMCHECKBOX Paper bags FORMCHECKBOX Tote bags FORMCHECKBOX Tote boxes FORMCHECKBOX Other (specify): FORMTEXT ?????How are incoming products transported? FORMTEXT ?????Are incoming product transport units inspected prior to loading with organic product? FORMCHECKBOX Yes FORMCHECKBOX NoIs the inspection/cleaning process documented? FORMCHECKBOX Yes FORMCHECKBOX NoAre transport units used to carry any prohibited substances? FORMCHECKBOX Yes FORMCHECKBOX NoAre organic products shipped at the same time as nonorganic in the same transport units? FORMCHECKBOX Yes FORMCHECKBOX NoCheck all steps take to segregate organic products: FORMCHECKBOX Dedicated organic only transport units FORMCHECKBOX Organic product shrink wrapped FORMCHECKBOX Pallet tags identifying "organic" FORMCHECKBOX Separate area in transport unit FORMCHECKBOX Use of pallets FORMCHECKBOX Other (specify) FORMTEXT ?????IN-PROCESS:How are in-process products transported? FORMTEXT ?????How do you insure that in-process transport units are cleaned prior to loading organic products? FORMTEXT ?????Is the inspection/cleaning process documented? FORMCHECKBOX Yes FORMCHECKBOX NoOUTGOING FINISHED PRODUCT:In what form are finished products shipped? FORMCHECKBOX Cardboard cases FORMCHECKBOX Cardboard drums FORMCHECKBOX Dry bulk FORMCHECKBOX Foil bags FORMCHECKBOX Mesh bags FORMCHECKBOX Metal drums FORMCHECKBOX Tote bags FORMCHECKBOX Tote boxes FORMCHECKBOX Paper bags FORMCHECKBOX Plastic crates FORMCHECKBOX Other (specify) FORMTEXT ?????How are outgoing products transported? FORMTEXT ?????How do you insure that outgoing transport units are clean prior to loading organic products? FORMTEXT ?????Is the inspection/cleaning process documented? FORMCHECKBOX Yes FORMCHECKBOX NoAre transport units used to carry any prohibited materials? FORMCHECKBOX Yes FORMCHECKBOX NoAre organic products shipped at the same time as nonorganic in the same transport units? FORMCHECKBOX Yes FORMCHECKBOX NoCheck steps taken to segregate organic products: FORMCHECKBOX Dedicated organic only transport units FORMCHECKBOX Organic product shrink wrapped FORMCHECKBOX Pallet tags identifying “organic” FORMCHECKBOX Separate area in transport unit FORMCHECKBOX Use of pallets FORMCHECKBOX Other (specify) FORMTEXT ?????SECTION 8: InternationalNOP Rule §205.406Indicate which (if any) of the following countries you intend to import organic products from or export organic products to. FORMCHECKBOX Canada FORMCHECKBOX European Union FORMCHECKBOX Japan FORMCHECKBOX Korea FORMCHECKBOX Switzerland FORMCHECKBOX TaiwanIf you are exporting to or importing from the European Union, are you authorized in TRACES to initiate a Certificate of Inspection? FORMCHECKBOX Yes FORMCHECKBOX NoThe following substance is not allowed in production or handling of organic products that will be exported to Canada. Indicate if all inputs are free of: FORMCHECKBOX Sodium or Chilean NitrateSECTION 9: Final FeesNOP Rule §205.406To continue certification, a certified operation must annually submit Final Fees due to Minnesota Crop Improvement Association. See the Organic Fee Schedule and Scale of Sanctions for applicable final fees. The Final Fee submission forms and instructions are available in electronic format on the MCIA website, . Handlers seeking to continue certification must include a Handler Organic Final Fees Submission Form and payment along with this application.SECTION 10: AffirmationNOP Rule §205.100, 205.400 and 205.401I affirm that all statements made in this application are true and correct. I agree to comply with the Organic Foods Production Act of 1990 and National Organic Program Rules and Regulations. I understand that the facility may be subject to unannounced inspection and/or organic products may be sampled and tested for residues at any time. I agree to provide further information as required by the certifying agent.Signature of Owner/ManagerDateI have attached the following additional documents: FORMCHECKBOX Applicable Fees—see the Organic Fee Schedule and Scale of Sanctions* FORMCHECKBOX Handler Organic Final Fee Submission Form and annual payment* FORMCHECKBOX Annual Organic Handler Agreement* FORMCHECKBOX This questionnaire, completed and signed* FORMCHECKBOX Multi-ingredient Product Profiles for all multi-ingredients products requested for certification or re-certification* FORMCHECKBOX Labels for ingredients FORMCHECKBOX Finished product labels FORMCHECKBOX Labels for other substances used (boiler additives, cleansers, pesticides) FORMCHECKBOX SDSs, if applicable FORMCHECKBOX Pest management map of traps and monitors FORMCHECKBOX Water test, if applicable FORMCHECKBOX Facility map FORMCHECKBOX Product flow chart FORMCHECKBOX Other (specify) FORMTEXT ?????*REQUIREDI have made copies of this questionnaire and other supporting documents for my own records: FORMCHECKBOX Yes FORMCHECKBOX NoSubmit completed forms, fees, and supporting documents to:Minnesota Crop Improvement Association1900 Hendon AveSaint Paul, MN 55108 ................
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