No Form number WA. Potatoes Inspection Certificate Failing M.O. Require

OMB No. 0581-0178

S tate of Washington Potato Committee

P.O. Box 1815, Moses Lake, Washington 98837

Phone (509) 765-8845 / FAX (509) 765-4853

INSPECTION CERTIFICATE FAILING MAREKTING ORDER 946 REQUIREMENTS

Shipper’s Name: ___________________________________ Shipper’s Special Purpose Certificate Number: _________________________

Shipping Point _____________________________________ Destination: ___________________________________________________

Date of Failed Inspection: ___________________ CWT Amount Failed: _______________ Variety: ________________________

TO COMPLY WITH FEDERAL MARKETING ORDER 946, PLEASE CHECK THE APPROPRIATE BOX AND FILL OUT THE REQUESTED INFORMATION.

Certificate Number	Federal/State Inspection Reason for Failing Marketing Order 946

• 1. If any of these potatoes were sent for processing, please list the following:

Processor’s name: ________________________________________________________________________________________________

Address: ______________________________________________________ State: __________________ Zip Code: _______________

Phone Number: ____________________________ CWT Shipped: ______________ Date of Shipment: ________________

• 2. If any of these potatoes were sent for animal feed, please list the following:

Name: __________________________________________________________________________________________________________

Address: ______________________________________________________ State: __________________ Zip Code: _______________

Phone Number: ____________________________ CWT Shipped: ______________ Date of Shipment: ________________

• 3. If any of these potatoes were sent to Charity, please list the following:

Charity name: ____________________________________________________________________________________________________

Address: ______________________________________________________ State: __________________ Zip Code: _______________

Phone Number: ____________________________ CWT Shipped: ______________ Date of Shipment: ________________

• 4. If any of these potatoes were re-run and re-inspected, please list the following:

Name of Packer/Shipper: _________________________________ Inspection Reference Number(s):_____________________________

Address: ______________________________________________________ State: __________________ Zip Code: _______________

Phone Number: ____________________________ CWT Shipped: ______________ Date of Inspection: ________________

Attach Copy of Passing Inspection Certificate(s).

I, the undersigned, a shipper responsible for the handling of the above potatoes, do hereby certify that the disposition shown for each lot above is the true disposition for each of these lots.

Title___________________________________________ Signature________________________________________________________________

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 3 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.