| U.S. Department of Agriculture | OMB APPROVED NO. 0580-0013 | 
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		| Grain Inspection, Packers and Stockyards Administration | 
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		| QUESTIONNAIRE FOR PROPOSED DIVERTER-TYPE | 
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		| MECHANICAL SAMPLER | 
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		| Facility Name, City, State | 
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		| Field Office | 
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		| Kind of Elevator | 
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		| Authorization Code - Circle Appropriate Numbers | 
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		| D  Diverter      N  Non-diverter      P  Probe      0  All Grains      1  Small Grains      2  Coarse Grains - Not Corn | 
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		| 3  In      4  Out      5  Cargo      6  Barges      7  Hopper Cars      8  Carlots      9  Trucks | 
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		| D/T Make and Model | S/N | 
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   | Spout / Belt Size | 
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		| General Location | Spout / Belt Name | Spout / Belt Angle | Belt Speed | 
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		| Power: | Body Dimensions | Pelican Stroke | Pelican Opening     L x W | 
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		| Grain Drop Before Sampler | Grain Drop After Sampler | Access Safe | Inspection Door OK? | 
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		| Verified No Auxilliary Controls | Location of Lockout OK? | Lights OK for Exams? | 
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		| Is Pelican Movement Steady? | Does Pressure Return Promptly? | Air Pressure at Rest PSI | 
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		| Timer Make and Model | Grain Flow Rate Past Sampler | Calculated Timer Setting | 
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		| Secondary Make and Model | S/N | Delivery System | Grams per Sample | 
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		| Total No. of Samples | Quantity Adjustment Sealed? | Delivery and Collection Box Secure? | Excess Returned to Lot? | 
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		| Dust Control Locations | 
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		| Weights: | 
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		| NO SCALE | 
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		| Number of Shipping Bins: | Depth | Graded | Procedures to Stop Breakage: | 
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		| Remarks/special restrictions when used to sample officially: | 
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		| Signature of Official Personnel: | Date: | 
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		| FORM FGIS-998 (7/04)   Previous edition may be used.  Expires January 2015 | 
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 | DIRECTIONS FOR COMPLETING QUESTIONNAIRE | 
	
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 | 1. Facility name, city, and state. | 
	
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 | 2. Name of FGIS field office. | 
	
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 | 3. Check the box indicating kind of elevator. | 
	
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 | 4. Storage capacity of elevator. | 
	
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 | 5. Authorization Code-circle the numbers that apply to the intended sampler use. | 
	
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 | 6. Sampler Make & Model; e.g., Gamet 6800S. | 
	
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 | 7. Sampler Serial Number. | 
	
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 | 8. Is the sampler in a spout or on a belt end? For spout samplers-diameter or length x width | 
	
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 | cross sectional measurements or; | 
	
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 | 9. Belt Size-width and depth of grain carried. | 
	
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 | 10. General location of sampler; e.g., Headhouse 6th Floor; or Gallery. | 
	
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 | 11. Spout/belt name; e.g., Scale #1 lower garner. | 
	
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 | 12. Spout angle-90_ is vertical. Belt Angle-0_ is horizontal. Show normal angle and max/min | 
	
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 | limits of travel, if angle can be varied. | 
	
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 | 13. Belt speed-measure with belt loaded. | 
	
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 | 14. Check the box showing type of power. | 
	
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 | 15. Body dimensions for the sampler. | 
	
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 | 16. Pelican stroke is the distance traveled from one side to the other. | 
	
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 | 17. Length and width of the pelican opening. | 
	
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 | 18. Distance in feet from release point. | 
	
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 | 19. Distance grain falls is used to estimate impact and breakage. For example, measure from | 
	
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 | sampler to bin bottom. | 
	
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 | 20. Is access to the sampler by approved ladder or stairs, and does the platform have an | 
	
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 | approved railing? | 
	
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 | 21. Are the inspection doors properly located on the sampler? Do they have appropriate seal | 
	
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 | hasps and hinges? | 
	
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 | 22. Check verified after you determine that the system controls have no bypasses, dump | 
	
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 | counters, timer interrupts, or programmable controllers. | 
	
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 | 23. Location of lockout ok-does the lockout provided meet FGIS requirements? | 
	
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 | 24. Light for examinations-can all exterior examination checks be made with lighting supplied? | 
	
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 | 25. For pneumatic/hydraulic samplers-is pressure sufficient to move the pelican across the | 
	
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 | stream of grain evenly, without lagging or slowing down. | 
	
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 | 26. For pneumatic/hydraulic samplers-pressure returns to maximum before next cut is initiated. | 
	
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 | 27. For pneumatic samplers-gauge pressure at rest. Maximum reached when no cuts are | 
	
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 | initiated. | 
	
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 | 28. Timer Make & Model; e.g., Eagle HP5 Model 9. | 
	
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 | 29. Flow past sampler should be figured out by timing a known amount, such as one scale draft, | 
	
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 | as it passes the sampler. | 
	
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 | 30. Calculate the timer setting in seconds based on grain flow rate past sampler. Also show | 
	
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 | whether this is based on a 200, 350, or 500 bushel sampling rate. | 
	
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 | 31. Secondary Sampler (divider) Make & Model; e.g., InterSystems MD300. | 
	
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 | 32. Secondary Sampler Serial Number. | 
	
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 | 33. Check box indicating type of sample delivery system. | 
	
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 | 34. Weight in grams received for the official sample. | 
	
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 | 35. Total number of samples needed for all interested parties. | 
	
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 | 36. Are the quantity adjustment features on secondary sampler fixed or sealed in place? | 
	
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 | 37. Is the sample delivery system secure from the air inlet to the collection box? | 
	
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 | 38. Is excess grain automatically returned from the secondary to the lot from which the sample | 
	
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 | was taken? | 
	
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 | 39. Location of dust collection ducts-are they located where they can affect the sample | 
	
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 | constituents? The measurements will serve as a record of approved duct work. | 
	
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 | 40. Weights-are weights official; i.e., supervised under the USGSA as Class X or Y-are weights | 
	
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 | Certified; i.e., supervised unofficially by a local organization-or are weights unofficial and | 
	
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 | not supervised, or not provided? | 
	
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 | 41. Shipping bins-number used. | 
	
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 | 42. Shipping bin depth(s). | 
	
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 | 43. Grading-will bin be held for grade or factor results before being released? | 
	
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 | 44. Procedures to stop breakage-will the bins require use of cushion level indicators, grain | 
	
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 | ladders, or baffles to reduce impact of grain and resulting breakage? | 
	
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 | 45. Carrier identification or stowage locations. | 
	
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 | 46. Special restrictions-any special procedural restrictions; e.g., weighback belt must be sealed, | 
	
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 | turnhead must be locked in position, cushion must be maintained in shipping bin, etc. | 
	
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 | 47. Name or signature of the official personnel who filled out the questionnaire. | 
	
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 | 48. Date information obtained. |