FGIS-9601 Repair/Modification Notice

FORM APPROVED OMB NO. 0580-0013 (FGIS-9601)

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 0580-0013. The time required to complete this information collection is estimated to average 2 minutes per response and 2 minutes of recordkeeping, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Expires January 2015.

U.S. DEPARTMENT OF AGRICULTURE GRAIN INSPECTION, PACKERS AND STOCKYARDS ADMINISTRATION FEDERAL GRAIN INSPECTION SERVICE FIELD MANAGEMENT DIVISION REPAIR/MODIFICATION NOTICE	SERIAL NUMBER (Optional)
	NAME AND LOCATION OF FACILITY
	DATE	TIME AM PM

EMERGENCY BREAKDOWN NON-EMERGENCY BREAKDOWN	REQUESTED BY
	PERSON NOTIFIED
MALFUNCTION NOTED
HANDLING/DELIVERY SYSTEM SCALE(S) SYSTEM GRAIN SPILLS(S) REMARKS:
ACTION TO BE TAKEN BY FGIS
UNTIL REPAIR OR MODIFICATION IS COMPLETED, WEIGHT CERTIFICATION: WILL BE DISCONTINUED WILL CONTINUE WILL CONTINUE UNDER THE FOLLOWING CONDTIONS:
REPAIR/MODIFICATION COMPLETED
DATE	TIME AM PM
_____________________________________________ (Name of Official Personnel)

FGIS-9601 (6/04) (Replaces Form FGIS-9601 which may be used)

Instructions for Use. To complete the Repair/Modification Notice, enter the following information:

1. Enter the scale serial number (optional).

2. Enter the name and location of facility.

3. Enter the date the form was prepared.

4. Enter the time the form was prepared.

5. Check block ‑ emergency breakdown or non-emergency breakdown.

6. Enter the name of official personnel (Supervisor or Scales Specialist) requesting repair or modification.

7. Enter the name of elevator person notified.

8. Check appropriate block to fit malfunction and explain in remarks what the malfunction is and its location.

9. Check appropriate block and explain the conditions under which weighing will continue.

10. Enter the date of the completion of repair/modification.

11. Enter the time the repair/modification was completed.

12. Enter the name of the official inspection personnel who observed the completion of the repair/modification.

Distribution. Complete the notice up to, and including, the "Action To Be Taken By FGIS" section. Give the person notified of the necessary repairs or modifications a copy of the notice. After the repairs or changes are made, complete the "Repair/Modification Completed" section of the notice and send a copy to the field office.

CONTACT INFORMATION:

Contact the field office responsible for the geographic area in which the service is provided. Details for these locations can be found at:

http://www.gipsa.usda.gov/GIPSA/webapp?area=forms&subject=landing&topic=fgis

For further information on the Repair/Modification Notice:

William Bates

Policies and Procedures Branch

Field Management Division

1400 Independence Avenue, SW, Room 2409 N

Washington, DC 20250-3630

Telephone 202-690-0961

Fax 202-720-1015

[email protected]