WMB 24-15 (NRY) CA Walnuts Rept. Substandard Walnuts Received (Non-Reser

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OMB NO. 0581-0178

Walnut Marketing Board
1540 River Park Drive,Suite 203
Sacramento CA 95815-4609
Ph (916) 922-5888 Fax (916)923.2548

WMBForm #24-15 .
(NoneReserve Year)

REPORT OF SUBSTANDARD WALNUTS RECEIVED
This report of substandard walnuts received Is submitted In compnance with the requirements of the Federal Marketing Order
No. 984, 8Samended. In executing this fonn, the Substandard User respectively certifies to the Walnut Marketing Board and to
the U.S. Department of Agriculture as to the correctness and completeness of their statement

Instructions:

1.
2.
3.

All deliveries must be made to Approved Substandard Users.
Complete the information below.
Mail a copy of the form to the Walnut Marketing Board (WMB) following each delivery.
Handlers will complete WMB Form #20, Report of Substandard Walnuts Delivered. The
WMB will match the forms to verify disposition of substandard walnuts.

DFA Inspection Certificate
Number (If applicable)

Weighmaster Certificate
Number (If available)

Net Weight

The above kemelweight of walnuts was delivered by:
Handler:
Delivery Date:

Delivered To:

Name of Approved User:
By:

Title:

The making of any false statements or representations Inany matter within the Jurisdictionof any agency of
the United States, knowing Itto be false, Is a violation of Title 18, Section 1001,United States Code, which
provides for the penalty of a fine of $250,000for Individualsand $500,000for organizations or Imprisonment
of not more than five 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
information collection is 0581-0178. The time required to complete this information col1ection is estimated to average 15
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.
The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis ofrace, 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 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 TOD). 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 calI (800) 795-3272 (voice) or (202) 720-6382 (TDD).
USDA"is an equal opportunity provider and employer.