ACP-5 Minimal Testing Form

OMB No. 0581-0215

Administrative Committee for Pistachios

4938 East Yale Avenue, Suite 102

Fresno, CA 93727

Tel (559) 255-6480; Fax (559) 255-6485

Email: [email protected]

MINIMAL TESTING FORM

This form is submitted to the Administrative Committee for Pistachios if you handle less than 1,000,000 Pounds (assessed weight) of pistachios in a given production year. Upon approval of this form the ACP will give the Handler the option of complying with the FMO according to section 983.53.

Section A: Handler must complete this form and mail to the ACP by August 1^st prior to each production year. The handler is responsible for retaining a copy of the completed form for their own records for 3 years following the production year in which the pistachios were shipped.

Handler Name: ________________________________________________________________________ Address: ___________________________________City: _____________ State:____ Zip Code: ______

Assessed weight handled: ___________________________________________________________ Lbs.

Production Year: ______________________________________________________________________

Handler signature: ________________________________________ Date: _________________

Name: _________________________________________________ Title: _________________

Section B: To be completed by the ACP committee.

Approved / Denied By: ____________________________________________ Date: ________________

Name: __________________________________________________________Title: ________________

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 0581-0215. The time required to complete this information collection is estimated to average 6 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.

ACP-5 (Rev. 08/10. Destroy previous editions.)