PMC 4.71A CA Dried Prunes Users Receipt of Dried undersized Prunes

_ __
u

...UU..-

---

--

Form PMC 4.71A
OMB 10581-0178

USER'S RECEIP1' OF DRIED UNDERSIZEDPRUNES FOR NON-HUMANUSAGE

P-5 Inspection
Cenificatc #

Handler

The undersigned certifies to the United States Department of Agriculture and to the Prune Marketing Committee that the
following described load of dried undersized prunes was received for non-human usage. The undersigned hereby agrees to
permit access, by an authorized representative of the Prune Marketing Committee or the United States Department of
Agriculture, to any plant or other facility where the dried undersized prunes received hereunder are stOred or used, and to all
books and records, during the usual business hours, pertaining to any undersized prune activity. Said books and records will
be held for such inspection for a period of two years from the date of fmal usage of the undersized prunes;

Net Prune
Weildlt

Location

Nameof
TruckinllC

Prunes to be
Used fo

Date
Received

-Where truck unloaded:

Name of firm receiving prunes:

Address of firm:

Signature & Title:

Date:
Instructions: Complete and return the original to the Prune Marketing Committee, 3841North Freeway Blvd, Ste. 120,
Sacramento, Ca 95834; PMC will forwarda copy to your supplier;retain a copy for your records.
IMPORTANT NOTICE
This report is requiredby law (7 U.S.C. 608 (d), 7CPR §993.50,and §993.150(g) (2) (iii).
FAIL~

TO .u:PORT canresult in a fine ofnot I~s

~

$50.<,JO

or morethan$5,000for eachsuchviolationandeachday duringwhich

such Violation continues shall be deemed a separate Violation. The lSSWIJlCe
of a false certificate, knowing it to be false. is a violation of Title
18, Section 1001 of the United States Code, which provides a penalty of a fine of not more than $10,000, or imprisonment of not more than
S years, or both.

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 infonnation collection is 0581-0178. The time
required to complete this information collection is estimated to average 5 minutes per response, including the time for reviewing instructions,
searching existing data sources, ~g
and maintaining the data needed. and completing and reviewing the collection of information.
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 infonnation (Braille, large print, audiotape, etc.) should
contact USDA's TARGET Center at (202) 720-2600 (voice and TOO).
To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building. 1400 Independence Avenue,
SW, Washington, DC 20250-9410 or call (202) 720-5964 (voice and TOD). USDA is an equal opportunity provider and employer.