WA-303 Original and/or Amendment Examination Report

Form Approved - OMB No. 0560-0120
1. CODE NO.

U.S. DEPARTMENT OF AGRICULTURE
Farm Service Agency

WA-303
(11-01-04)

ORIGINAL AND/OR AMENDMENT EXAMINATION REPORT
(See Page 2 for Privacy Act and Public Burden Statements)
A. SECTION

2. LICENSE NO.

3. AMENDMENT NO.

B. LOCATION (City, County, Parish and State)

4. THIS REPORT APPLIES TO:
6. RAILROAD SERVING THE SECTION

5. APPLICANT IS:
A. OWNER

OR LESSEE OF LAND

B. OWNER
A. VOLUME

OR LESSEE OF WAREHOUSE
B. PAGE

C. COUNTY

D. STATE

7. IF OWNER OF LAND, GIVE RECORDING
OR TAX INFORMATION
8. IF LESSEE OF LAND OR WAREHOUSE, GIVE THE FOLLOWING INFORMATION (Note: obtain a copy of all leases).
A. LESSOR:

B. EXPIRATION DATE:

9. CONSTRUCTION
A. UPRIGHT WAREHOUSE
CONCRETE

B. FLAT WAREHOUSE

METAL

CONCRETE

WOOD

C. DETACHED OR TANKS
METAL

WOOD

CONCRETE

METAL

WOOD

10. ADDITIONAL DESCRIPTIVE COMMENTS:

11. HANDLING EQUIPMENT
A.
TYPE

B.
NO.

C. CAP. PER HOUR
BU.

CWT.

D. RECEIVING (ü)
Rail

Truck

Water

E. SHIPPING (ü)
Rail

Truck

Water

LEG(S)
LEG(S)
LEG(S)
LEG(S)

F.
G.
TURNING SCALES*
(ü)
TRUCK
TRUCK
HOPPER
HOPPER

CONVEYOR

H.
CAPACITY

I.
UPLOAD
(ü)

J.
LOADOUT
(ü)

TRACK

DRYER(S)
CLEANER(S)

* If none, state where weighed.

12. PORTABLE EQUIPMENT
B. CAP. PER HOUR
A. TYPE
BU.

C. HANDLING CAPABILITY NORMAL WORKWEEK
LOAD OUT
UNLOAD

CWT.

AUGER
PNEUMATIC LOADER
FRONT END LOADER

BU.

CWT.

BU.

CWT.

RAIL CAR
TRUCK
BARGE
VESSEL

D. TRACK CAPACITY
(Number of cars that can be
unloaded/loaded without switch)
CAR DUMP

CARS

HOPPER CAR PIT

CARS

HOPPER CAR SPOUT

CARS

13. IS STORAGE SPACE EQUIPPED WITH:
YES
NO
YES
THERMOMETER SYSTEM:
NO
YES
AERATION:
NO
DUST COLLECTOR:
14A. AGRICULTURAL PRODUCTS WILL BE STORED:
14B. ARE ELIGIBLE AGRICULTURAL PRODUCTS NOW STORED IN
THIS SPACE?
OTHER (Specify:)
BULK
BAG
YES
NO
15. ARE AGRICULTURAL PRODUCTS WEIGHED BY OR UNDER SUPERVISION OF:
FGIS
WAREHOUSE OPERATOR
OTHER APPROVED AGENCY (Name)
16. ARE AGRICULTURAL PRODUCTS GRADED BY:
FGIS
WAREHOUSE OPERATOR
FGIS APPROVED AGENCY
OTHER
17. IS SUFFICIENT EQUIPMENT AVAILABLE FOR GRADING PRODUCTS?
YES

NO

If "NO", where are products graded?

18. IF THE ENTIRE BUILDING IS NOT TO BE INCLUDED UNDER LICENSE, THE BUILDING MUST BE PROPERLY PARTITIONED. (DESCRIBE PARTITION AND MATERIALS
USED TO CONSTRUCT IT IF APPLICABLE):

19. IF PRODUCTS OTHER THAN THOSE TO BE INCLUDED UNDER LICENSE ARE TO BE STORED OR HANDLED, NAME SUCH PRODUCTS AND COMMENT ON
POTENTIAL DANGER:

20. DOES WAREHOUSE OPERATOR HAVE COMPLETE CONTROL OF WAREHOUSE
SPACE?
NO
YES
If "NO", comment in Item 25 "Remarks"
22. ARE THERE ANY CONDITIONS HAZARDOUS TO EXAMINERS?
YES

NO

24A. EXAMINER'S SIGNATURE

If "YES", comment in Item 25 "Remarks"

21. IS THERE ANY UNDUE FIRE, FLOODING, OR OTHER HAZARD?
YES

NO

If "YES", comment in Item 25 "Remarks"

23. DO YOU RECOMMEND ISSUANCE OF A WAREHOUSE OPERATOR'S
LICENSE?
NO
If "NO", comment in Item 25 "Remarks"
YES

24B. DATE SIGNED (MM-DD-YYYY)

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WA-303 (11-01-04)

(Page 2 of 2)

25. REMARKS

NOTE:

The following statement is made in accordance with the Privacy Act of 1974 (5 U.S.C. 552a) and the Paperwork Reduction Act of 1995; as amended. The authority for
requesting the following information is 7 CFR Parts 735 and 1421.5554. Furnishing the requested information is voluntary; and no penalty will be imposed for failure to
respond. However, a response is required in order to be considered for a warehouse license (7 U. S. C. 242) and the decision as to the applicant's eligibility for a license
must be made in part on the basis of the information provided. 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
data needed, and completing and reviewing the collection of information. RETURN THIS COMPLETED FORM TO 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.