SEW SWE DEPARTMENT OF HEALTH Quarterly Controlled Substance Inventory Form for ureau of Narcotic Enforcement Humane societies Title 10 of New York State Rules and Regulations Part 80.134(k) states: ?Quarterly reports. Within 10 days of the end of each quarter of each year, the society or facility shall submit a report to the department signed by an of?cer or of?cial and the agent and (the information requested by this form). FacilityName Fl?l ?ll? calf? Agent?s Name L- t: Cl? Flt?. 0 Address Lac: I r? (?I?rtgu?x ?rnpr hf MUiniQ-d- State 3? Zip @112 ?d Telephone Number - 7 cl (.3 (j Bureau of Narcotic I 0 0 3L0 DEA Number Quarter (1) (2) (31? year Ll? Circle correct quarter CONTROLLED SUBSTANCE Mixture of Sod. Pcntobarbital (Schedule Ketamine (Schedule [11) Previous Amount on Hand 3p) 9 (K . ?2 Total Amount Received 00 - (a .t Total Amount Utilized :91) I if (83 . 0 *Total Amount Lost Ending Amount on Hand 50; S- i f) a Number of Dogs Euthanized i Number of Cats Euthanized 2-7 Other Species Euthanized (specify) Loss of rolled substances usl be reported to the Bureau of Narcotic Enforcement. Brie?y explain the loss. Signed: W. Print Name:O Ll Eri??ti I are To be completed by registered agent: I certify that on conducted a physical inventory on the controlled substances above. Any 10 has been noted. Under the penalties of 'ury, I af?rm thatthe statements made are true. gWrH? new. re of Agent ure of Of?cer of Society or Facility 1? Its-if (new? Date Date False statements made herein are punishable as a Class A misdemeanor, pursuant to section 210.45 ofthe Penal Law. Mail completed forms to: Bureau of Narcotic Enforcement Riverview Center 150 Broadway Albany, NY 12204 (866) 811-7957 OOH-4331 (n12) am of Heal?! ms Bene?t? NEW DEPARTMENT OF HEALTH ama Quarterly Controlled Substance Inventory Form for Bureau of Narcotic Enforcement . . .6. muof?eme Humane Socletles Title 10 of New York State Rules and Regulations Part 80.13460 states: ?Quarterly reports. Within 10 days of the end of each quarter of each year, the society or facility shall submit a report to the department signed by an of?cer or of?cial and the agent and include. (the information requested by this form). Facility Name Hi [113/ {1f} {flit- Agent?s Name I 0 Address [reg r1" man '6_lfi__?_gmr lei bL/ juices. swan. Telephone Number Ll Bureau ofNar ber Quara?m (4) ofyear I rcle correct quarter CONTROLLED SUBSTANCE Mixture of Sod. Pentabarbital (Schedule Ketamlne (Schedule Previous Amount on Hand '2 C) a Total Amount Received I 7) (2:0 0 Total Amount Utilized a 3 .9 8 *Total Amount Lost a Ending Amount on Hand I Number of Dogs Euthanized Number of Cats Euthanized C) Other Species Euthanized (specify) Loss of coyolled substances st be reported to the Bureau of Narcotic Enforcement. Brie?y explain the loss. Signed: m3 Print Name: Ll7mtrl?: 60 Vi C) To be completed by registered agent: I certify that on Ef?iibl conducted a physical inventory on the controlled substances above. Any loss ha been noted. Under the penalties I af?rm that the - [ements made are true. . Si of Of?cer of S?ciety or Facility Date False statements made herein are punishable as a Class A misdemeanor, pursuant to section 210.45 of the Penal Law. Mail completed forms to: Bureau of Narcotic Enforcement Riverview Center 150 Broadway Albany, NY 12204 (866) 8114957 OOH-4331 (7/12) SEW YORK STATE DEPARTMENT 0" Quarterly Controlled Substance Inventory Form for ureau of Narcotic Enforcement Humane societies Title 10 of New York State Rules and Regulations Part 80.13400 states: ?Quarterly reports. Within 10 days of the end of each quarter of each year, the society or facility shall submit a report to the department signed by an of?cer or official and the agent and (the information requested by this form). FacilityName If!" fifti( pit} ll?i?tlli (ll?jc'l'i?f. if 1 Agent?s Name i 51 if (H 0 Address U5 Fl r? were?: Hf.th ml M- F. - POIl?Pslir?ik Zip County NJC-ti?l?td I) .s, . Telephone Number . 3 Q?l ?7 0 0 Bureau of Narcoti i 0 DEA Number Quarter /l corrch quarter CONTROLLED SUBSTANCE Mixture of Sod. Ketamine Previous Amount on Hand - Total Amount Received Total Amount Utilized *Total Amount Lost Amount on Hand Number of Do Euthanized Number of Cats Euthanizcd Other Euthanized Loss of itlrolled substance must be reported to the Bureau of Narcotic Enforcement. Brie?y explain the loss. Signed: We ?Md/"p jute!) Print Name?j ?lm-\ri pl a" To be completed by registered agent: I certify that on Lil?1(in conducted a physical inventory on the controlled substances [lifted above. Any lame been noted. Under the penalties af?rjury, I af?rm that statements made are true. ri?e/arm fee/?AL. W75;an of Agent Winn: of Of?cer af?rmier or Facility sis?if {1815? Date Date False statements made herein are punishable as a Class A misdemeanor, pursuant to section 210.45 of?re Penal Law. Mail completed forms to: Bureau of Narcotic Enforcement Riverview Center 150 Broadway Albany, NY 12204 (866) 811-7957 DOH-4331 (7/12) I II- - I - PIPE-w-?mr-w?m} 7 '2313-