01/07/2015 16:38 FAX 9146320445 canon. 0001/0001 Quarterly Controlled Substance Inventory Form for Humane Societies; Title 10 ofNew YorkS l?Rules and Regulations Part "Quarterly reports Withln 10 days of the end ofeach quarter of each year, the society or facility shall submit a N- rt to the department signed by on officer or of?cial and the agent and (the information requested by this form). Facility Name it) Ht: mom. 3601051 Agent?s Name t1 1M 0 .32.. . Address w_f?l 0! Po F1 (took- .. __State Zip 1030 Telephone Numbeli <3:2 9 cl 6 I .nforcetneut Certi?cate Number_ mega? Bureau of Narcotic DEA Number Quarter (1) (2) (3) @oryear c1 0] Circle correct quarter -r Previous Amount (:11 Hand 5.69 Total Amount Resolved - Total Amount [?ied _l II *Total Amount Lg Cj - a ?uid-I" . if. To Number of Dogs Eithanized Lf 7 Number of CatsE hanized (f Other Species Eu??uimd (specify) i 7? 9.1? 2'Airdy 0 Loss of controllo? substances must be reported to the Bureau of Narcotic Enforcement. Brie?y explain the loss. Signed: Print Name: want: I Certify that on ed. Under the penalties I 433 River Street, Suite 303 Troy, NY 12180 i (518) 402-7070 Don-4331 {31637 YS Department of Health fNarcOttc EnfOrCeme Humane Societies Title 10 ofNew York State Rules and Regulations Part 30. 134(k) states: ?Quarterly reports. Within days of the end at each quarter of each year, the society or facility shall submit a repon to the department signed by an of?cer or ol?cinl and tug-enraan incluzle_,. (the information requested by this form). Facility Name fl i??ii? 360.16?! . Agent?s Name Address 1m or. mack R'?dft State Zip i0 $6 i Counly_bJ_Q :3 Telephone Number Bureau of Narcotic Enforcement Certi?cate Number_ 0 9.2 L0 DEA Number Quarter (3) (4) of year :20! 3 Circle correct quarter CONTROLLED SUBSTANCE Mixture 0f sod. Pentobarbital (Schedule Ketamine Schedule Previous Amount on Hand 1/ 1 Total Amount Received Total Amount Utilized =2 5., (.9 *Total Amount Lost a Ending Amount on Hand I 2 Number of Dogs Euthanized I Number of Cats Euthanized Other Species Euthanized (specify) n? ?at, E13, 3 {5:751} Loss of controlled substances must be reported to the Bureau of Narcotic Enforcement. Brie?y explain the loss. Signed: Print Name: - To be completed by registered agent: I certify that on lf?/bI conducted a physical inventory on the controlled substances listed above. Any 105 has been noted. Under the penalties of pajama af?liate inade are true. Sign?iirei 'ggrt 4 Siglianj?? ofO??cer fSociety or Facility ?7 . 7/ Date Date False statements made herein are punishable as a Class A na'sdemeanor, pursuant to section 210.45 af?ne Penal Law. Mail completed forms to: Bureau of Narcotic Enforcement 433 River Street, Suite 303 Troy, NY 12180 (518) 402-7070 OOH-4331 (3/06) NEW YORK STATE DEPARTMENT OF ?5"st Department of Haiibrterly Controlled Substance Inventory Form for Bureau of Narcotic Enforcement . OCT 1 3 2015 Humane Socretles Bureau of Narcotic Enforcement Title to ot'Ncw York State Rules and Regulations Part 80.134(k) states: "Quarterly reports. Within 10 days of the end of each quarter el'each year, the society or facility shall subtnil a report to tire department signed by an of?cer or of?cial and the agent and (the information requested by this form). Facility Name hi. Agent's Name ~13 OH. i ll Address GIL R0 NW R93 Statew_ Zip County igh?d bf" Telephone Number (a 3 Bureau of Narcotic (Q DEA Number Quarter (1) (2) 637(4) of year .30; 5 Circle correct quarter CONTROLLED SUBSTANCE Mixture of Sod. Pentobarbital @chedule Ketamine (Schedule Previous Amount on Hand ?7 3 Total Amount Received 5 Total Amount Utilized 1 51 <2 1' ft? *Total Amount Lost o? 3? Ending Amount on Hand LI 1? at. Number of Dogs Euthanized i lot Number of Cats Euthanized 3 Other Species Euthanized {specify} '3 ?4,711, [k 2 Loss of controlled substances must be reported to the Bureau of Narcotic Enforcement. Briefly explain the loss. Signed: Print Name: To be completed by registered agent: I certify that on Ell/[Q I conducted a physical inventory on the controlled substances listed above. Any ass has been noted. Under the penalties of pet?Jtlt Him/Inge made are true. inf-f]? 3? t? If) Signiiture of Agent Signatur?tif (j?i71rt70ciety or Facility . {x Mir/ta Date 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) 811-7957 OOH-4331 (7H2) ILII I ..