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 numbers for these information
collections are 0579-0088 and 0579-0102. The time required to
complete these information collections is estimated to average
1.00 hour 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.
OMB
Approved
0579-0088
EXP
XX/XXXX
U.S.
DEPARTMENT OF AGRICULTURE
ANIMAL
AND PLANT HEALTH INSPECTION SERVICE
PLANT
PROTECTION AND QUARANTINE
REPORT
OF VIOLATION
SERIAL
NO.
1.
DATE VIOLATION DISCOVERED
2.
VIOLATED - REG/COMPL. AGREEMENT
3.
WHERE INTERCEPTED (City
or Port, and State; also county if domestic)
4.
ORIGIN OF ARTICLE (Include
county, if domestic)
5.
ARTICLE MOVED IN VIOLATION OF REGULATIONS
6.
IDENTITY OF ARTICLE (Serial
No., Waybill No., Description, etc.)
7.
NAME AND BUSINESS ADDRESS OF VIOLATOR (Shipper,
caterer, cleaner, garbage handler,
servicing
agent, broker, ship's agent, etc. Identify which)
8.
VIOLATOR HAD
COMPLIANCE
AGREEMENT?
YES
NO
Permit?
YES
NO
9.
IF NO, WAS VIOLATOR AWARE OF REGULATION?
YES NO
UNKNOWN
IF
"YES,"HOW INFORMED AND WHEN?
10.
NAME AND BUSINESS ADDRESS OF CARRIER
11.
WAS CARRIER AWARE OF REGULATION?
YES NO
UNKNOWN
IF
"YES," HOW INFORMED AND WHEN?
12.
IDENTITY OF CARRIER
13.
NAME AND BUSINESS ADDRESS OF CONSIGNEE
PLANE
AIRCRAFT NUMBER
FLIGHT
NUMBER
SHIP
FLAG
NAME
ROAD
VEHICLE License No.
14.
DISPOSITION OF PEST RISK (i.e.,
articles named in Item 5 were fumigated, destroyed, etc.)
15.
REMARKS (Attach
additional sheet, if needed)
16.
VIOLATOR OR CARRIER'S STATEMENT OF VIOLATION (Attach
additional sheet, if needed. Identify who gave statement.)
17.
OFFICER'S STATEMENT: Must attach a detailed, signed, and dated
statement. State how the action violated the regulations or
compliance agreement cited in
Item
2. Describe fully the facts of the violation from discovery
through disposition of pest risk including when, who, what, and
where.
18.
SIGNATURE OF INITIATING OFFICER
19.
PRINTED NAME OF OFFICER AND WORK UNIT
20.
DATE REPORT COMPLETED
21.
OFFICER IN CHARGE COMMENTS (Attach
additional sheet, if needed)
LIST
PREVIOUS VIOLATIONS
RECOMMENDATIONS
22.
SIGNATURE OF OFFICER IN CHARGE
23.
PRINTED NAME OF OFFICER IN CHARGE AND WORK UNIT