For
Name of Farm
The information in this document is a true representation of the food safety conditions and practices followed at this location.
Owner or manager responsible for food safety / Signature / Date
Grower Information
Site Information
Name and location of farm: / Farm mailing addressSite configuration
Total building(s) footprint size (sq ft)
/Actual total growing area (sq ft)
/Grower food safety team members (at least 2 required)
Name and Title / Contact InformationWork Home
1 (Coordinator) / · Tele:· Fax:
· Email: / · Tele:
· Fax:
· Email:
2 / · Tele:
· Fax:
· Email: / · Tele:
· Fax:
· Email:
3 / · Tele:
· Fax:
· Email: / · Tele:
· Fax:
· Email:
4 / · Tele:
· Fax:
· Email: / · Tele:
· Fax:
· Email:
/
Substrate Preparation and Storage at This Location
Phase I / Phase I substrate conducted on-site / Phase I received from off-site supplier / Ingredients and/or finished Phase I substrate stored on-sitePhase II / Phase II substrate preparation conducted on-site / Phase II received from off-site supplier / Ingredients and/or finished Phase II substrate stored on-site
Phase III (bulk spawn run) / Bulk spawn run received from off-site supplier / Bulk spawn run stored on site
Water Use and Source (check all that apply)
Use\Source / Municipal / Private WellDrinking / /
Hand Washing / /
Cleaning food contact surfaces / /
Irrigation / /
Toilet Facilities (check all that apply)
Indoor facilities / Portable units / None on site
Cleaning and Maintenance of Toilets
Performed by grower / Contracted service
Availability of Toilet Facilities
Maximum number of employees on site at any one time / Number of toilet facilities within ¼ mile walk / Ratio of employees to toilet facilities (min 20:1 required)
Number : / Number : / Ratio:
Sewage Treatment (check all that apply)
Municipal / Septic System / Portable containment system
Reviewed by: / Date: