Produce Safety

Produce Safety Rule Exemption Application

Farm Information

Farm Name:
Physical Address:
Physical Zip:
Physical City:
Physical State:
Farm Phone:
Farm Email:

Mailing address same as physical address:

Mailing Address:
Mailing Zip:
Mailing City:
Mailing State:

Name of Farmers Market where produce is sold:

Contact Information

Contact First Name:

Contact Last Name:

Contact Phone:

Contact Email:

Other Information

Farm Size Based On Average FOOD Sales (in the past 3 years): * Food Sales – includes all food for humans, feed for animals, & sales of live food animals

Number of water sources per source type:

Protected Well:
Surface Water:
City or Rural Water:
Other:

Does your Farm use Soil Amendments of Animal Origin (ex. Chicken Litter)?

Please fill in your growing season:

Plant Date:

Harvest End Date:

Acreage:

Amount of Acreage Farmed:

Please check all that applies to your farm:

Grow produce

Harvest produce

Pack produce

Hold produce

List of crops grown, harvested, packed and held:

Covered Produce (Check all boxes for Covered Produce that you grow)

Non-Covered Produce (Check all boxes for Non-Covered Produce that you grow)

Has your company taken the PSA grower training class?

Date taken: