pursuant to: * Animal Health Protection Act (chapter P-42, s. 55.15)
* Marine Products Processing Act (chapter T-11.01, s. 45, par. 5)
* Other Act
Name and address of person in charge Report No.
A- REASONS FOR ACTIONS TAKEN
Considering the reasons mentioned in offence report No. respecting
(name and address of person concerned)
dated , I took the samples described in the document attached hereto, to be shipped or delivered, at room temperature *, refrigerated * or frozen *, on at _________o’clock by
to the * Laboratoires d’expertise et d’analyses alimentaires or * Laboratoire de
(means of transport)
pathologie animale. Seals are affixed to the sample containers. Project No. At the time of the swabbing, the surface used was cm2.
B- SAMPLING (Method and procedures used - representativeness of the sample, etc.)
C- DESCRIPTION AND CHARACTERISTICS OF THE SAMPLE
In addition to the record number and the name and address of the person concerned, I indicated, on the document attached hereto, the data and characteristics that I have personally observed in respect of each sample, particularly the place where the sample was taken, its number, the seal number, nature of the product, trademark, number of the lot to which it belongs, quantity taken, temperature of the sample when it was taken and, where applicable, the date on which the sample product was packaged, its "best before" expiry date or any other information likely to prove the authenticity of the sample.
Made in triplicate at
(place) * Document(s) attached
I have personally observed the facts and taken the actions mentioned in *A *B *C I have personally observed the facts and actions mentioned in *A *B *C
Authorized person Authorized person
Surname and given names (in block letters) Surname and given names (in block letters)
Authorized person’s No. or position Authorized person’s No. or position
(Form prescribed by regulation to be used as documentary evidence)