No Form number OR/CA Potatoes--Load Report Sheet Waiver of Inspection

OMBNo.OS81-o178
U.S. DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE
FRUIT AND VEGETABLE PROGRAMS

Oregon-California Potato Committee
700 NE Multnomah, Ste. 460, Portland, OR 97232-4104
Questions? Call (503) 731-3300

Load Report Sheet Waiver of Inspection

INSTRUCTIONS
Handlers complete all information below your column for all potatoes delivered to the same consignee. For the column - Delivery Information, please Indicate a Railroad Car Number, Truck
Ucense. Following delivery to the consignee, make a copy of this report for the consignee and promptly return the original to the Committee. If you are performing as a handler and consignee,
please complete both sections and send completed original to the Committee within 15 days of shipment. Consignee - complete all Information below your column and make a copy of this report
for the handler and promptly return the original to the Committee. The undersigned certifies to the Committee and the Secretary of Agriculture that the following Information is correct and in
accordance with the Waiver of Inspection requirements. Falsification of Informationon this government document may result in a fine of not more than $10,000 or imprisonment of not more than
five (5) years, or both (18 U.S.C. 1001). Failure to comply will result In cancellation of waiver.

-

CONSIGNEE INFORMATION

HANDLER INFORMATION
Business Name

I

Business Name

Full Address

Full Address

I

PhoneCs)

PhoneCs)

I Date I

Signature
Date of
Shipment

Delivery Information

I

I

I Date I

Signature
Container Size and Type

Hundredweight Shipped

TOTAL

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 OS81-o178. The time required to complete this information collection is estimated to average 10 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)
720-2600 (voice and TDD). To file a complaint of discrimination, write to USDA, Director, Office of Civil Rights, 1400 Independence Avenue, S.W., Washington, D.C. 202S0.9410, or call (800) 79S-3272 (voice)
or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.
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