1 =Dairyman=.................. =Owner= ..................... 2 =P. O. Address=............. =P.O. Address=.......State... 3 =County=..... State..... =Party Interviewed=............ 4 Milk delivered to Creamery at.......... Formerly at......... 5 Operated by.................. Address....................... 6 Distance of farm from Creamery..... Occupied farm since..... 7 No. Cows....... No. Milking...... No. Qts. Produced......... 8 All persons in the households of those engaged in producing or handling milk are............free from all infectious disease. Weekly reports are..................being filed .......................................................... 9 Date and nature of last case on farm........................ 10 =WATER SUPPLY= for utensils is from a............... located .......... feet deep and apparently is............ pure and wholesome............ State any possible contamination located within 200 feet of source of water supply or if water supply is not protected against surface drainage ........................................................... ........................................................... 11 Water supply on this farm analyzed.... 191.. Result........ 12 Style of Cow Barn.... Length.... ft. Width.... ft. Height of ceiling.... ft. 13 =Dairy Rules= of the Department of Health are........ posted .................. 14 =Dairy Herd= examined by............. on.............. 191.. Report............