No Form number WA Potatoes--Shippers Application for Modification of In

STATE OF WASHINGTONPOTATOCOMMITTEE

OMB #0581-0178

P.O. Box 1815, Moses Lake, Washington 98837

Shipper's Application for Modification of Inspection Privilege. Potatoes
ContactName:

Farm/CompanyName:

Address:
Phone:

County:
Acres

Variety

Approximatevieldper acre

Typeof PackMade:
Cartons:

Consumer
Packs:_
(5's,10's,15's,20's)

ToteBins:

100# Sacks:

25#Sacks:

50#Sacks:

Bulk loads:

Approximate Dackoutper month(cwt):

----January February March

April

May

June

--July

August SeptemberOctoberNovemberDecember

Numberof packersinarea:
location of nearestSWIS office:
Approximatemilesone way:
I, the undersigned applicant, agree to the following:
1. Complywith all the requirementsof MarketingOrder946;
2. Promptlyreportall potatoespacked, shipped and marketed;
3. Promptlypay all inspectionfees and assessments;
4. Apply annuallyfor a renewalof permit;
5. Failure to complywith MarketingOrder946 may result in the cancellationof the Waiverpermit.
6. Informationprovidedis subject to verificationby the SWPCanellorUSDA.

Signature
ofApplicant

Date

Permissionis hereby gantedldeniedto the aboveshipperfor Modificationof InspectionPrivilege.

Signatureof Committee Chairman or Manager

Date

According to the Paperwak Reduction Act of 1995, an agency may not conduct or sponsor, and a per.;cn is not required to respond to a col3ction of information unEss ~ displays a wid OMS control
number. The wid OMB control number for this information col3ction is 0581~178. The time required to compete this information col3ction is estimated to 8\IeI'8Q85 minutes per response, incuding
the time for reviewing instructions, searching existing data sources, gathering and mainteining the data needed, and competing and reviewing the col3ction of information.
The U.S. Department of Agriculure (USDA) prohibits discrimination in al ~ programs and activities on the basis of ra:e, cobr, national origin, age, disabilty, and where applcabla, sex, mailal stetus,
familal stetus, J8mIaI stetus, relgion, sexual orientation, genetic information, pollical belefs, reprisal or becwse aI or part of an individuals income is derived from any pubic assistance program (Not
al prohibited bases app~ to aI programs.) Persons v.ith disabilties I'ttJorequire atematr.e means for communication of program information (Brait!, Bge print, audiotape, etc.) shouk! contact USDA's
TARGET Center at (202) 720-2600 (..ace and TOO). To fila a complaint of discrimination, write to USDA, Director, Office of QvjlRights,1400IndependenceA_,
S.W.,Washington,D.C. 2025(}.
9410, oreal (800) 795-3272 (..ace) cr (202) 720-6382 (IDD). USDA is an equal opportunity prrMder and empbyer.