COC-155 California Olives Special Purpose Shipment

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OMB #i0581-0178

REPORT OF SPECIAL PURPOSE SHIPMENTS

COC-155
04-01

Crop Year:

TO: CaliforniaOliveCommittee
1903 North Fine #102
Fresno CA93727

FROM:

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EIN#:
The above handler is requesting permission to package and market the following experimental shipments -in order to conduct marketing
re~earch and develo ment ro.ects. For each a lication, the- re uestin handler must rovide information including, but not limited to;

Purpose of request:

Market Outlet:

Place.of Inspection:

Quantitv

VarietyCies)

Time Frame:-

Anticipated Date of Pack:
Fruit
Size

Style

Container
Type:
Black/Green
Size
Can Code

Type of Flavoring
other amendments etc.

Certification and Signature: The undersigned, on behalf of the reporting handler, certifies to the CaliforniaOliveCommittee and the
Secretary of Agriculture of the United States that all MarketingOrder reporting requirements for receipt and disposition have been met;
that all assessments under the MarketingOrder have been met; and that this fruit willbe kept separate from other packaged olives
by _~ means satisfactory to the Inspection Service.

Title

Signature
COC USE
ONLY

Inspection Notified:
Date:

Date

Note: The following statements are made in accordance with the Privacy Act of 1974 (5 U.S.C. 5518) and the Paperwork Reduction
Act of 1995. The authority for requesting this information to be supplied on this form is the Agricultural Marketing Agreement Act of
1937, Sees. 1-19,48 Stat. 31, as amended, (7 U.S.C. 601-674). Furnishing the requested information is necessary for the
administration of the marketing order program.

Accordingto the PaperworkReduction Act of 1995, an agency may not conduct or sponsor,and a person is not requiredto respondto
a collectionof informationunless it displaysa valid OMB control number. The validOMB control number for this information
collectionis 0581-0178. The time requiredto complete this informationcollectionis estimatedto average20 minutes per response,
includingthe time for reviewinginstructions,searchingexistingdata sources, gathering and maintainingthe data needed, and
completingand reviewingthe collectionof information.
The U.S. Department of Agriculture (USDA) prohibits discrimination in aU its programs and activities on the basis of race, color,
national origin, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation,
genetic information, political beliefs, reprisal, or because all or part of an individual's income is derived from any public assistance
program (Not aUprohibited 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 to USDA. Director, Office of Civil Rights, 1400 Independence Avenue, S.W.,
Washington, D.C. 20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider
and employer.