No dealer shall send or accept any shellfish without a signed statement attached showing:
(1) The name of the consignor.
(2) The name of the consignee.
(3) The number of the consignor’s certificate of shellfish sanitation issued at the point of origin and the date of harvesting or packing, if the consignor is required by law to have a certificate of shellfish sanitation.
(4) The source of the shellfish and the fact of certification of the source by the State Department of Agriculture or certification by a state whose shellfish program is indorsed by the United States Public Health Service, if such certification is required by law.