No Form No. CO. Potatoes - Waiver of Inspection - Weekly Shipment Re

OMB No. 0581-0178

Colorado Potato Administrative Committee Phone: 970-352-5231

Area III - Northern Colorado Fax: 970-304-0861

P.O. Box 1774

Greeley, CO 80632

WAIVER OF INSPECTION - WEEKLY SHIPMENT REPORT

Dates: Week beginning _____________, and ending _____________ (inclusive)

To be submitted to the Colorado Potato Administrative Committee (Committee) at the close of business each Friday. (Duplicate copy to be retained by Handler.) If necessary, attach additional sheet to complete information.

Origin Report of Potatoes Handled - Received

Name, Address, Phone	Quantity/Variety Received	Carrier ID	Original Inspection Certificate No. and Date	Purpose *

*regrade, resort, and/or repack

Shipment Report of Potatoes Handled - Shipped

Name, Address, Phone	Quantity in CWT.	Type and Size of Container	Carrier ID No.

__________________________________________ ___________________________________________________

Handler Address

__________________________________________ ___________________________________________________

Authorized Representative Phone and Fax Number

False certification, knowing it to be false, is a violation of title 18, section 1001, of the United States Code, among other statures, which provide for a fine, imprisonment, or both.

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 9 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 USDAA's TARGET Center at 202-720-2600 (voice and TDD).

To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, DC 20250-9410 or call (800)795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.

State of Colorado MO Docket A-4 (Rev. 10/2010. Destroy previous editions.)