PMC 4.7 CA Dried Prunes Converters Certificate of Dried Prunes f

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Form PMC 4.7
OMB0581-0178

PRUNE MARKETING COMMITTEE
Certificate #
CONVERTERS'S CERTIFICATE OF DRIED PRUNES FOR NON-HUMAN USAGE

Warehouse
Release

Manifest
#

Manifest
Wei

Nameof Trucker

Date
Received

Tractor
License#

Trailer
License#

CONVERTER'S CERTIFICATE OF NON-HUMAN USAGE OF DRIED PRUNES
The undersigned hereby certifies to the United States Department of Agriculture and to the Prune Marketing
Committee that the above described prunes were used for animal feed or were ground with other feed materials to
produce animal feed on before
at the following location.
(Date)
Location of feeding area or feed mill:

Nameoffinn:
Address:
Signature:

Title:

Date:

INSTRUCTIONS: Execute in triplicate, completing all entries for which you have data and send the original and
one copy to P.M. C., 3841 North Freeway Blvd., Suite 120, Sacramento, CA 95834. Be sure date of certification is
on or after the date shown for completing the certificate.

IMPORTANT NOTICE
The issuanceof a falsecertificateknowingit to be false is a violationof Title 18, Section1001of the UnitedStates
Code,whichprovidesa penaltyof a fineof not morethan S10,000or imprisonmentof not morethan 5 years or
both.
According to the Papenvork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of
i'lformation unless it displays a valid OMB control number. The valid OMB control numberfor this information collection IS0581-0178. The time required to
complete this information collection is estimated to average 5 minutes per response, meluding the time for reviewing mstmctions, searching existing data
sources, gathering and mamtaining the data needed, and completing and reviewing the collection of i'lformation. The U.S. Department of Agriculture (USDA)
prohibits discrimination in a/l its programs and activities on the basis of race, color, national origin, gender, religion, age, disability, political beliefs, sexual
orientation, and mantal or family status. (Not all prohibited bases apply to a/l programs.) Persons with disabilities who require alternative means for
communication of program i'!formation (Brai/le, large print, audiotape, etc.) should contact USDA's TARGET Center at (202) 720-2600 (voice and TDD). 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 TDD). USDA is an equal opportUnityprovider and employer.