WA-561 Original Warehouse Examination Report (Processed Commodi

WA-561
(01-21-04)

Form Approved - OMB No. 0560-0120
LEAVE BLANK - USDA USE ONLY
A. REVIEWED BY
B. DATE (MM-DD-YYYY)

U.S. DEPARTMENT OF AGRICULTURE
Farm Service Agency

ORIGINAL WAREHOUSE EXAMINATION REPORT
(Processed Commodities)
N
O
T
E

1. TYPE OF STORAGE:
DRY
COOLER

FREEZER

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. 7 CFR Part 1423.4 authorizes the collection of the
following data. This information will be used to determine eligibility of warehouses for storing Government-owned or loan commodities. Furnishing the requested information is voluntary; however, without
it the Commodity Credit Corporation may cancel the applicable Storage Agreement. This information may be furnished to any agency responsible for enforcing the provisions of the contract. 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 (KCCO), WAREHOUSE LICENSE AND EXAMINATION DIVISION, STOP 9148, P.O. BOX 419205 KANSAS CITY, MO 64141-6205.

2. NAME AND ADDRESS OF WAREHOUSE

3. NAME OF WAREHOUSE MANAGER OR SUPERINTENDENT

TELEPHONE NO.
FAX NO.
(Area Code):
(Area Code):
E-MAIL ADDRESS:
4. HAVE YOU VERIFIED APPLICABLE ITEMS ON APPLICATION FORM (If corrections are made on Form CCC-560, they must be initialed by the
warehouse operator and any discrepancies must be explained in detail.)
YES

NO

5A. DOES FIRE PROTECTION APPEAR ADEQUATE?

YES

NO

6A. DID YOU FIND EVIDENCE OF EXCESSIVE MOISTURE
OR DRYNESS IN WAREHOUSE?

YES

6B. IF "YES," HOW ARE PRODUCTS PROTECTED?

NO

7A. IS WAREHOUSE NEAR A STREAM OR BODY OF WATER?

YES

5B. IF "NO," EXPLAIN:

7C. IF "YES," GIVE DATE OF LAST FLOOD
7B. IF "YES," TO WHAT HEIGHT DOES
(COMMENT ON SUBSEQUENT PROTECTIVE
WATER RISE ON BUILDING AT HIGHEST
MEASURES IN REMARKS)
WATER MARK?

NO

8. COMMENT ON WAREHOUSE OPERATOR'S EXPERIENCE IN STORING OR HANDLING COMMODITIES

9. OTHER ACTIVITIES IN WAREHOUSE (Include products stored for other than USDA and indicate "field warehouse" operations, if any)

YES

NO

10. Is 1st floor (not basement) above ground level on all sides?
11. Is the warehouse under control of the warehouse operator at all times?
12. Does the warehouse appear to be of sound construction and in good condition?
13. Are facilities adequate for receiving, storing, and delivery?
14. Are commodities stacked to allow for appropriate housekeeping?
15. Are sanitation and housekeeping practices satisfactory?
16. Is a tempering and grading room available (cold storage)?
17. Do you recommend approval?
If "NO," to any of Items 10 through 17, explain in Item 18, Remarks or form WA-101.
18. REMARKS

19A WAREHOUSE EXAMINER (Signature)

19B. DATE (MM-DD-YYYY)

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.