LPS-518-1 Alleged Violation and Detention Notice

OMB APPROVED - NO. 0581-0113
U.S. DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE
LIVESTOCK, POULTRY, AND SEED PROGRAM

ALLEGED VIOLATION AND DETENTION NOTICE

The authorities for requesting the information to be supplied on this form and any supplements are the Egg Products
Inspection Act (21 USC 1031-1056) to provide a mandatory inspection program & the Agricultural Marketing Act of 1946
(7 USC 1621-1627) to provide a voluntary grading program. This form is used to report alleged violation(s) of the EPIA
(Secs. 5,8,10,11,19, and 20) or the AMS (Sec. 203(h)) & as a notice & record of detention of product in noncompliance
with these Acts.
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 0581-0113. The time required to complete this information collection is estimated to
average .25 hours 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.

1. NAME AND ADDRESS OF VIOLATOR

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.
2. DATE OF REPORT

4. ALLEGED VIOLATION OF

3. DATE OF VIOLATION

5. TYPE OF VIOLATION

EGG PRODUCTS INSPECTION ACT
AGRICULTURAL MARKETING ACT
VOLUNTARY REGULATIONS, PART
OTHER
6. DESCRIPTION OF PRODUCT (Class, type, state, number of containers, net weight, description of labels, USDA marks, grading/inspection sampling results, etc.)

Shipped
Received

7. CERTIFICATION: I certify (1) that the product described above was received or shipped by us as noted and (2) that the shipping records(s), if any, and invoice(s), or copies thereof furnished to or copied by an
authorized representative of the Secretary of Agriculture, cover the shipment(s) described.
NAME OF AUTHORIZED PERSON (Type or print name and sign.)

TITLE

8. NAME AND ADDRESS OF SHIPPER

9. NAME AND ADDRESS OF PROCESSOR

10. NAME AND ADDRESS OF RECEIVER OR BUYER

11. NAME AND ADDRESS OF TRANSPORTER (or carrier)

12. NAME AND ADDRESS OF TRUCK DRIVER

13. LOCATION OF PRODUCT

DATE

14. DISPOSITION OF PRODUCT (Detained, denatured, etc.)

15. TRUCK LICENSE NUMBER

16. SHIPPING RECORDS INVOICES (Date and description, attach copy)

17. DESCRIPTION OF PLACARD OR ADVERTISEMENT (Copy, facsimile, or sketch attached)

18. NAME AND DATE OF NEWSPAPER (Attach copy of article)

19a. NAME AND ADDRESS OF REGULATORY INSPECTOR

19b. TELEPHONE NUMBER OF REGULATORY INSPECTOR (Include area code)

19c. SIGNATURE OF REGULATORY INSPECTOR

IF PRODUCT IS DETAINED - COMPLETE ITEMS 20, 21, AND 22 BELOW
20. NUMBER(S)

DETAINED TAG(S) ATTACHED TO PRODUCT
21. DATE

22. DETENTION NOTICE RECEIVED BY (Signature)

The product described above is DETAINED by the Agricultural Marketing Service (AMS), U. S. Department of Agriculture (USDA), for a period not to exceed twenty (20) days in accordance with the authority
contained in the EPIA. The detention identification shall not be detached, defaced, or destroyed and the detained product shall not be removed from detention and used, moved, or altered in any manner without first
being released by an authorized representative of the AMS, USDA, under penalty of fine and/or imprisonment. Voluntary disposition of the product to prevent its use as human food, or placing the product in
compliance, will result in termination of the detention. Seizure, condemnation and disposal of such product shall be as directed by any United States District Court or other proper court as provided in the EPIA.

LPS-518-1 (01-2015)