No Form number OR/CA Potato Cmte. Special Purpose Shipment Report

OMB No. 0581-0178

OREGON-CALIFORNIA POTATO COMMITTEE

9320 SW BARBUR BLVD., SUITE 130

PORTLAND, OREGON 97219-5405

Phone: (503) 731-3300 / Fax: (503) 239-4763

SPECIAL PURPOSE SHIPMENT REPORT

INSTRUCTIONS: Handlers: complete all information below your column for all potatoes delivered to the same receiver. For Delivery Information, please indicate a Railroad Car Number, Truck License. Following delivery to the receiver, make a copy of this report for the receiver and promptly return the original to the Oregon-California Potato Committee (Committee). If you are performing as a handler and receiver, please complete both sections and send completed original to the Committee within 15 days of shipment. Receivers: complete all information below your column and make a copy of this report for the handler and promptly return the original to the Committee. The undersigned certifies to the Committee and the Secretary of Agriculture that the following potatoes are being diverted from fresh channels in accordance with Oregon-California Potato Committee Regulations. Falsification of information may result in a fine or imprisonment, or both (18 U.S.C. 1001). Failure to comply will result in cancellation of certificate.

HANDLER INFORMATION

ULTIMATE RECEIVER INFORMATION

Business Name

Business Name

Full Address

Full Address

Phone(s)

Phone(s)

Certificate of Privilege No.

State Potatoes Grown

Signature

Date

Signature

Date

Date of Shipment

Delivery Information

Inspection Certificate Number

Hundredweight Shipped

Date Potatoes Received

Type of Use

Hundredweight Received

TOTAL

TOTAL

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.