WA-221 Examination Report

Form Approved - OMB No. 0560-0120
See Page 2 for Privacy Act and Public Burden Statements
2. LICENSE AND CODE
NO.

U.S. DEPARTMENT OF AGRICULTURE 1. NAME AND LOCATION OF WAREHOUSE
Farm Service Agency

WA-221
(06-02-05)

3. CUTOFF DATE
(MM-DD-YYYY)

EXAMINATION REPORT
(Supplement 1)
A. RECORDS AND ACCOUNTS:
4. DESCRIBE THE SYSTEM OF ACCOUNTS AND STOCK RECORDS USED

5B. IF "NO", EXPLAIN

5A. IS A FIREPROOF SAFE, VAULT, OR COMPARTMENT PROVIDED
FOR SAFEKEEPING OF RECEIPTS AND RECORDS?

YES

NO

B. FIRE-PROTECTION EQUIPMENT AND WAREHOUSE SECURITY:
6. DISTANCE TO NEAREST
FIRE STATION

10. NUMBER OF HYDRANTS

9. IS HYDRANT SYSTEM PROVIDED?

YES

8. IF WATER SUPPLY IS FROM, OR SUPPLEMENTED BY, OTHER THAN CITY
CONNECTIONS, EXPLAIN FULLY

7. WHAT IS THE SOURCE OF WATER SUPPLY?

11. SIZE OF HYDRANTS

NO

12. LOCATION OF HYDRANTS

13. ADEQUATE HOSE PROVIDED?

YES
14A. DESCRIBE ANY ADDITIONAL FIRE PROTECTION EQUIPMENT
INCLUDING PUBLIC FACILITIES

14B. WATCHMAN SERVICE
OTHER
FIRE

15A. IS THE WAREHOUSE PROPERTY ENCLOSED?

SECURITY
15B. IF "YES," HOW?

YES

14C. IF WATCHLOCK USED
(Explain below:)

NO. STATIONS

HOURLY
HALF HOURLY

NO

16. IS A WRITTEN SECURITY PLAN IN PLACE THAT INCLUDES MEASURES TO PROTECT COTTON
HANDLED AND STORED?
17. HAS WAREHOUSE OPERATOR CONDUCTED A FACILITY VULNERABILITY ASSESSMENT
AND ESTABLISHED PROCEDURES THAT ADDRESS (EACH OF THE FOLLOWING)?
A.
B.
C.
D.

NO

YES

YES

NO

NO

IF NO, ISSUE WA-125

IF "NO", ISSUE WA-125

GENERAL SECURITY OF THE PHYSICAL STRUCTURES AND GROUNDS OF THE WAREHOUSE,
SHIPPING AND RECEIVING PROCEDURES TO ENSURE THAT COTTON IS NOT SUBJECT TO TAMPERING,
ACTION TO BE TAKEN IN THE EVENT OF A NATIONAL EMERGENCY, AND
CONTACT INFORMATION FOR LOCAL SECURITY AUTHORITIES.

C. SHIPPING FACILITIES:
18. RAILROAD SERVING WAREHOUSE

19. WHAT OTHER SHIPPING FACILITIES ARE ACCESSIBLE?

20. CAN THE WAREHOUSE OPERATOR LOAD OUT ACCORDING TO THE
SHIPPING STANDARD? (If "NO", issue WA-125)

21. SIZE OF THE STAGING AND SHIPPING AREA

YES

NO

D. HANDLING EQUIPMENT:
22. DESCRIBE THE EQUIPMENT FOR RECEIVING, STORING, AND DELIVERING THE PRODUCT

23. NO. OF SCALES USED

24. TYPE

25. LOCATION

26. HOW OFTEN TESTED?

27. HOW TESTED?

28. ARE TEST WEIGHTS AVAILABLE?

YES

29. BY WHOM TESTED (Name or Title)?

NO

30. DESCRIBE SPACE OR CONTAINER PROVIDED FOR KEEPING LOOSE PRODUCTS OR SAMPLES

31. DO YOU RECOMMEND ISSUANCE OF A WAREHOUSE OPERATOR'S LICENSE AND/OR APPROVAL FOR
STORAGE OF GOVERNMENT LOAN OR OWNED COTTON?
NO
YES

IF "NO," EXPLAIN FULLY ON WA-101

All of the statements and answers on this and attached examination reports are true and correct to the best of my knowledge and belief.
32A. NUMBER OF ATTACHED WA-222's 32B. DATE SIGNED (MM-DD-YYYY)

32C. EXAMINER'S SIGNATURE

WA-221 (06-02-05)
NOTE:

Page 2

The following statements are made in accordance with the Privacy Act of 1974 (5 U.S.C. 552a) and the Paperwork Reduction Act of 1995, as amended. 7 CFR Part
735 authorizes the collection of the following data. This data is being collected to comply with the U.S. Warehouse Act, 7 U.S.C. 242 and Standards for Approval of
Cotton Warehouses, 7 CFR Part 1427. Data is used to determine whether licensee has required facilities and is operating in accordance with the Act, regulations or
contractual requirements. No warehouse license or contract approval may be granted unless pertinent information is obtained. Furnishing the data is voluntary;
however, without it assistance cannot be provided. This information may be furnished to any agency responsible for enforcing the provisions of the Act. This
information will not be disclosed outside of the U.S. Department of Agriculture except as required by law to the Department of Justice and the Department of Treasury.
This information may be provided to other agencies, IRS, Department of Justice, or other State and Federal law enforcement agencies, and in response to a court
magistrate or administrative tribunal. The provisions of criminal and civil fraud statutes, including 18 U.S.C. 286, 287, 371, 641, 651, 1001, 15 U.S.C. 714m, and 31
U.S.C. 3729, may be applicable to the information provided.
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless
it displays a valid OMB control number. The valid OMB control number for this information collection is 0560-0120. The time required to complete this information
collection is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the
date needed, and maintaining the data needed, and completing and reviewing the collection of information. RETURN THIS COMPLETED FORM TO YOUR KANSAS
CITY COMMODITY OFFICE, WAREHOUSE LICENSE AND EXAMINATION DIVISION, P.O. Box 419205, Kansas City, MO 64141-6205.

The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, gender, religion, age, disability,
political beliefs, sexual orientation, and marital or family status. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for
communication of program information (Braille, large print, audiotape, etc.) should contact USDA's TARGET Center at (202) 720-2600 (voice and TDD). To file a complaint of
discrimination, write USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call (202) 720-5964
(voice or TDD). USDA is an equal opportunity provider and employer.