WA-222 Examination Report of Individual Buildings

Form Approved - OMB No. 0560-0120

See Page 2 for Nondiscriminatory, Privacy Act, and Public Burden Statements.
U.S. DEPARTMENT OF AGRICULTURE
WA-222
Farm Service Agency
(11-01-04)

EXAMINATION REPORT OF INDIVIDUAL BUILDINGS
(Supplement 2)
1. NAME AND LOCATION OF WAREHOUSE

2. LICENSE AND CODE

4A. THIS REPORT APPLIES TO:

4B. DISTANCE TO HEADQUARTERS OFFICE

OWNER

C. EQUIPMENT IS

B. WAREHOUSE IS

5. APPLICANT'S INTEREST IN:
A. LAND IS:

3. DATE (MM-DD-YYYY)

LESSEE

6. IF OWNER OF LAND, GIVE RECORDING
OR TAX INFORMATION:

OWNER
A. VOLUME

LESSEE
B. PAGE

OWNER
C. RECORDS OF

LESSEE
D. STATE

COUNTY/
PARISH

7. SURROUNDINGS:
A. DISTANCE

B. LANDMARK

C. LANDMARK OWNER/TENANT USE

NORTH:

FEET TO:

OCCUPANCY:

EAST:

FEET TO:

OCCUPANCY:

SOUTH:

FEET TO:

OCCUPANCY:

WEST:

FEET TO:

OCCUPANCY:

8. TYPE OF CONSTRUCTION (Check one)
BRICK
9. NO. OF STORIES

CONCRETE

FRAME

10. AVERAGE HEIGHT EACH STORY
(floor to ceiling)

OTHER (Describe)

IRONCLAD

11A. LENGTH

11B. HEIGHT

11C. WIDTH

11. INSIDE DIMENSIONS:

STATE MATERIAL OF THE FOLLOWING:
12. FOUNDATION

13. BASEMENT FLOOR

14. GROUND FLOOR

15. OTHER FLOORS

16. ROOF

17. DOORS AND FRAMES

18. WINDOW SASH AND FRAMES

19. SKYLIGHT SASH AND FRAMES

20. STATE MATERIAL AND CONSTRUCTION OF FIREWALLS

21. STATE SUBSTANDARD FEATURES OF DIVISION FIREWALLS, IF ANY

22. STATE SIZE OF FIRE DOORS 23. MATERIAL

24. ACCEPTABLE CLOSING DEVICE
(If, "NO", Issue WA-125)

YES

NO

25. ACCEPTABLE LIGHTING
(If, "NO", Issue WA-125)

YES

NO

26. IF THE ENTIRE BUILDING IS "NOT" TO BE LICENSED, OR APPROVED, STATE HOW SPACE COVERED BY APPLICATION IS SEPARATED FROM SPACE "NOT"
COVERED:

27. IF BUILDING OR PARTS THEREOF, INCLUDING DOORS, WINDOWS, AND SKYLIGHTS, ARE IN NEED OF REPAIR, EXPLAIN FULLY:

28. ARE ANY OF THE FLOORS DAMP? IF "YES," STATE WHAT PORTION, GIVE CAUSE, AND DESCRIBE DUNNAGE USED, IF ANY:

29. IS WAREHOUSE EQUIPPED WITH HUMIDIFIERS? IF "YES," EXPLAIN FULLY:

30. IS THE BUILDING COVERED BY THIS REPORT PROVIDED WITH AUTOMATIC SPRINKLER?

IF "YES" IS IT: WET

DRY

31. NUMBER AND ARRANGEMENT OF INSIDE STANDPIPES:

YES

NO

WA-222 (11-01-04)

Page 2

32. IF PRODUCTS OTHER THAN THOSE COVERED BY THE APPLICATION ARE STORED IN THE SPACE, WILL THESE PRODUCTS
INCREASE THE FIRE HAZARD OR INJURE THE PRODUCTS COVERED BY THIS APPLICATION? IF "YES," EXPLAIN FULLY.

YES

NO

33. ARE ANY PRODUCTS NAMED IN THE APPLICATION NOW STORED IN THE PROPOSED SPACE? IF "YES," EXPLAIN FULLY.

34. IS STORED COTTON ARRANGED IN ACCORDANCE WITH UNDERWRITERS SPECIFICATIONS?
35. DOES ANY ADJOINING PROPERTY, OR NEARBY STREAM, CONSTITUTE A SECURITY, FIRE OR FLOOD HAZARD? IF "YES,"
EXPLAIN FULLY.

36. DO YOU RECOMMEND ISSUANCE OF A WAREHOUSE OPERATOR'S LICENSE AND/OR APPROVAL FOR STORAGE OF
GOVERNMENT LOAN OR OWNED COTTON? IF "NO", EXPLAIN IN ITEM 39.
37. DOES THE WAREHOUSE OPERATOR HAVE WRITTEN PERMISSION FROM THEIR UNDERWRITER TO DEVIATE FROM NORMAL
UNDERWRITING SPECIFICATIONS? IF "NO", ISSUE A WA-125.
38. DOES WAREHOUSE OPERATOR HAVE A SIGNED LEASE, IF APPLICABLE? IF "NO", ISSUE A WA-125 AND NOTE ON WA-101.
39. REMARKS (Attach additional sheets if necessary)

40A. EXAMINER'S INITIALS

NOTE:

40B. DATE (MM-DD-YYYY)

The following statements are made in accordance with the Privacy Act of 1974 (5 U.S.C. 552a) and the Paperwork Reduction Act of 1995, as amended. 7 CFR Part
735 authorizes the collection of the following data. This data is being collected to comply with the U.S. Warehouse Act, 7 U.S.C. 242 and Standards for Approval of
Cotton warehouses, 7 CFR Part 1427. Data is used to determine whether licensee has required facilities and is operating in accordance with the Act, regulations or
contractural requirements. No warehouse license may be granted unless pertinent information is obtained. Furnishing the data is voluntary; however, without it t
assistance cannot be provided. This information will not be disclosed outside of the U.S. Department of Agriculture except as required by law to the Department of
Justice and to the Department of the Treasury. This information may be provided to other agencies, IRS, Department of Justice, or other State and Federal law
enforcement agencies, and in response to a court magistrate or administrative tribunal. The provisions of criminal and civil fraud statutes, including 18 U.S.C. 286, 287,
371, 641, 651, 1001, 15 U.S.C. 714m, and 31 U.S.C. 3729, may be applicable to the information provided.
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 0560-0120. The time required to complete this information
collection is estimated to average 30 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. RETURN THIS COMPLETED FORM TO KANSAS CITY COMMODITY OFFICE,
WAREHOUSE LICENSE AND EXAMINATION DIVISION, P.O. Box 419205, Kansas City, MO 64141-6205.

The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, gender, religion, age, disability, political beliefs, sexual orientation,
and marital or family status. (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 USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400
Independence Avenue, SW, Washington, D.C. 20250-9410 or call (202) 720-5964 (voice or TDD). USDA is an equal opportunity provider and employer.