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

OMB No. 0581-0178

S tate Of Washington Potato Committee MODIFICATION OF INSPECTION REPORT

PO Box 1815, Moses Lake, WA 98837 (Reproduce Locally)

Name of Shipper		Shipped To/Receiver
Address		Address
City, State, Zip		City, State, Zip
Phone		Phone
Carrier		Destination

NOTICE: This report can only be used under the authority granted by the State of Washington Potato Committee (Committee), and is valid only if all the required information is contained herein. Any abuse or misuse of this form will result in the cancellation of modification of inspection privileges.

Variety (Russets, Reds, Etc.)	Date Shipped	CWT	Number & Type of Containers	Minimum Size	US No. 1, US No. 2, or No Grade

DISTRIBUTION: I, the undersigned, a duly authorized shipper, do herby certify that the quantity, and the

Please fax to the Committee: (509)765-4853 quality, and/or condition pertaining to said products were as herein stated.

________________________________________ ___________________________

Shipper’s Signature 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 OMB control number. The valid OMB control number for this information collection is 0581-0178. The time required to complete 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) 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. 20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.

Rev. 10/2010. Destroy previous editions.