No Form number WA. Potatoes Inspection Certificate Failing M.O. Require

OMB # 0581-0178

STATE OF WASHINGTON POTATO COMMITTEE
P.O. Box 1815/Moses Lake, Washington

98837

INSPECTION CERTIFICATE Failing Marketing Order 946 Requirements
Shipper's Name:

Shipper's Special Purpose Certificate Number:

Shipping Point

Destination:

Date of Failed Inspection:

CWTAmount Failed:

Variety:

TO COMPLY WITH FEDERAL MARKETING ORDER 946, PLEASE CHECK THE APPROPRIATE BOX AND FILL OUT THE REQUESTED
INFORMATION.

Certificate Number

o

1.

Federal/State

Inspection Reason for Failing Marketing Order 946

Ifany of these potatoes were sent for processing, please list the following:
Processor's name:

Address:

State:

Phone Number:

o

2.

CWT Shipped:

Ifany of these potatoes were sent for animal feed, please list the following:
Name:

Address:

State:

Phone Number:

o 3.

CWTShipped:

Ifany of these potatoes were sent to Charity, please list the following:
Charity name:
Address:

State:

Phone Number:

o

4.

CWTShipped:

If any of these potatoes were re-run and re-inspected,

please list the following:

NameofPacker/Shipper:
Address:

InspectionReferenceNumber(s):
State:

Phone Number:

CWT Inspected:

Attach Copy of Passing Inspection Certificate(s).
I, the undersigned, a shipper responsible for the handling of the above potatoes, do hereby certify that the disposition shown for each lot above, is
the true disposition for each of these lots.

Signature
Title
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