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Register December 2004 No. 588
Chapter ATCP 83
Grade A Permit # (if applicable) _________________
Name   License # (if applicable) _________________
City   State _________ Zip Code ___________
Name of Farm  
Address (if different)  
City   State _________ Zip Code ___________
Telephone (___) ____________________ Plant Receiving Milk___________________________________________
State of Wisconsin   )
    ) ss:
County of     )
I, __________________________________, as the owner or permit holder responsible for the dairy farm operation identified above, hereby certify as follows:
1. That no animals on the above farm are currently being treated with recombinant bovine somatotropin (rBST), also known as recombinant bovine growth hormone (rBGH);
2. That no animals on the above farm have received rBST treatments within the past 30 days;
3. That I will provide written notice to the buyer of my milk at least thirty (30) days in advance if I intend to use rBST on my dairy cattle; and
4. That I will not sell milk from animals added to my herd if those animals may have received rBST treatment within the previous 30 days.
I declare, under oath, that the above statement is true and correct to the best of my knowledge.
Producer Signature _______________________________,   Subscribed and sworn to before me this ________day of
______________________, 2____.
        Notary Public
_________________________ County, Wisconsin
My Commission Expires ____________________
Published under s. 35.93, Stats. Updated on the first day of each month. Entire code is always current. The Register date on each page is the date the chapter was last published.