KC-327 Bag manufacturer Declaration Sheet

Collection involves 10 or less individuals; See reverse for Privacy Act, Public Burden and Nondiscrimination Statements. therefore, OMB clearance not required.
KC327KCPBAGSDECLR U.S. DEPARTMENT OF AGRICULTURE CONFIDENTIAL (01-03-07) Farm Service Agency BAG MANUFACTURER DECLARATION SHEET Circular Woven Polypropylene Fabric/Bags
1. COMPANY NAME
     
2. PRODUCTION FACILITY ADDRESS						3. PHONE NUMBER
     						     
4. PRODUCTION CAPACITY
a. Number of Looms			b. Output per Loom (Meters per day)			c. Average Days of Operation per Week
     			     			     
5. FABRIC STYLE NO./PRODUCT CODE			6. ID MARKER YARN(S)			7. ID MARKER LOCATION
     			     			     
8. FORMULA BY PERCENTAGE
a. Polypropylene Resin	b. Calcium Carbonate		c. UV Resin Compound		d. Color Concentrate	e. Other (Specify):
     %	     %		     %		     %	     
						     %
9. 100% U.S. ORIGIN		10. 100% VIRGIN POLYMER		11. MEETS FDA REQUIREMENTS				12. COATING
Yes No		Yes No		Yes No				Yes No
13. LOT ID METHOD FOR TRACEABILITY
     
14. WARP AND FILL COUNT			15. TWISTED YARNS - If yes, enter frequency:
     	     		Yes No	Every       (Warp) X       (Fill)
Warp X Fill
16. FABRIC WEIGHT (Ounces per sq. yd.)		17. DENIER (Grams)		18. Color				19. SEWING (Threads per inch)
     		     		Beige White Buff				     
20. AIR PERMEABILITY Test Method: 3-30 cubic feet per minute per square foot per ASTM D 737
a. Tested By				b. Date			c. Results (cu. ft.)
     				     			     
21. IMPACT PERFORMANCE TEST Test Method: 195 inches per second velocity change – shock duration of .002 seconds
a. Tested By				b. Date			c. Results (Inches per second)
     				     			     
22. SLIDE ANGLE TEST Test Method: 28 degrees without slippage per TAPPI T-503-OM-84
a. Tested By				b. Date			c. Results (Degrees)
     				     			     
23. UV RESISTANCE PERCENTAGE Test Method: 70 percent retention after 200 hours per 5804-Federal Standard 191
a. Tested By				b. Date			c. Results (percent)
     				     			     
24. TENSILE STRENGTH Test Method: ASTM D 5034 (Grab test)
a. Pre-weathering Results (lbs. average warp)		b. Pre-weathering Results (lbs. average fill)		c. Post-weathering (lbs. average warp)				d. Post-weathering (lbs. average fill)
     		     		     				     
25. AUTHORIZED BAG MANUFACTURER REPRESENTATIVE
a. DATE ISSUED		b. ISSUED BY (Signature)
     
26. U.S. DEPARTMENT OF AGRICULTURE-FARM SERVICE AGENCY OFFICIAL
a. DATE		b. RECEIVED BY (Signature)
     

KC327KCPBAGSDECLR (REVERSE)

PRIVACY ACT AND PUBLIC BURDEN STATEMENTS

The following statements are made in accordance with the Privacy Act of 1974 (5 USC 552a) and the Paperwork Reduction Act of 1995, as amended. The authority for requesting the following information is 7CFR 1400, Subchapter C. The information will be used by approved bag manufacturers to perform testing on bags that are produced for export shipments. Furnishing the requested information is voluntary; however, failure to furnish the requested information will result in nonconsideration. 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 USC 286, 287, 371, 641, 651, 1001; 15 USC 714m; and 31 USC 3729, may be applicable to the information provided.

This collection involves 10 or less individuals; therefore, it does not require Office of Management and Budget (OMB) clearance. The time required to complete this information collection is estimated to average 15 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. Send comments regarding this burden estimate and any other aspect of this collection of information, including suggestions for reducing this burden estimate to U.S. Department of Agriculture, Kansas City Commodity Office, Chief, Business Operations Support Division, Stop 8768, P.O. Box 419205, Kansas City, Missouri 64141-6205.

NONDISCRIMINATION STATEMENT

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, SW, Washington, DC 20250-9410 or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.