Receiving Report Form - Ohio

DAIRY DIVISION
8995 East Main Street, Reynoldsburg, OH 43068-3399
Telephone: (614) 466-5550 Fax: (614) 728-2652
www.agri.ohio.gov/dairy Email: d
airy@agri.ohio.gov
RECEIVING REPO RT
DAIRY-3500-006.pdf (4/7/2010) Page 1 of 3
Milk Plant Name:
Month and Year:
License Number:
Pounds
Dairy Products
Received Utilized
Fee
Factor
Assessed Pounds
(Pounds x Factor) / 100
1 Grade A Raw Milk
1.00
2 Manufacture Raw Milk
0.50
3 Liquid Whey or Condensed Whey*
0.10
4
Dairy Products, Ice Cream Mix or
Cream*
1.00
5
Condensed Dairy Products (Not
including condensed whey)*
3.00
6 Dairy Powders Utilized*
11.62**
Total Assessed Pounds
* Product not derived from Grade A Raw Milk or Manufacture Raw Milk
** Dry Powder Blenders 5.00 onl y
I hereby certify that this information is correct to the best of my know ledge.
Signature Title Date
Email Address
Page 1/3
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Receiving Report Form - Ohio PDF

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