No Form number WA. Potatoes Shippers application for Modification of In

STATE OF WASHINGTONPOTATO COMMITTEE
108Interlake Road, Moses Lake, Washington 98837
Shipper's AplJlication for Modification of Inspection Pridlege

OMB #0581-0178

-Potatoes

Contact Name:

Farm Name:

Address:
Phone:

County:
Varietv

Acres

Aooroximate Yield oer acre

Tvoe of Pack Made:
Cartons:

Consumer Packs:
(5's, lO's, IS's, 20's)
100# Sacks:

25# Sacks:

50# Sacks:

Bulk Loads:

Tote Bins:

Aooroximate oackout oer month lcwt):
Jan.

Feb.

Mar.

Apr.

May

June

July

Aug.

Sept

Oct.

Nov.

Dec.

Nwnber of packers in area:
Location of nearest SWIS office:
Approximate miles one way:
I, the undenigned
1.
2.
3.
4.
5.
6.

applicant, agree to the fonowing:

Comply with all the requirements of Marketing Order 946;
Promptly report all potatoes packed, shipped and marketed;
Promptly pay all inspection fees and assessments;
Apply annually for a renewal of permit;
Failure to comply with Marketing Order 946 may result in the cancellation of the Waiver permit.
Information provided is subject to verification by the SWPC and/or USDA.

Signature of Applicant

Date

Check, if you want your name and address disclosed to the State of Washington
Potato Committee members.
Permission is hereby granted/denied to the above shipper for Modification of Inspection Privilege.

Signature of Committee Chairman or Manager

Date

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 OMBcontrol number. The valid OMBcontrol number for this Information collection is 0581-0178. The time required to compiete this
information collection Is estimated to average 5 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 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 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) 7202600 (voice and IDD). To file a complaint of discrimination, write to USDA, Director, Office of Civil Rights, 1400 Independence Avenue, S.w., Washington,
D.G. 20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382 (l'DD). USDA is an equal opportunity provider and employer.