No Form number WA Potatoes--Shippers Application for Modification of In

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

SHIPPER’S APPLICATION FOR MODIFICATION OF INSPECTION PRIVILEGE – POTATOES

Farm/Company Name: _______________________________________________ Contact Name: _______________________________

Address: ___________________________________________________________________________________________________________

Phone: ______________________________ County: ____________________________

Acres Variety Approximate yield per acre

_____ ______ ___________________

_____ ______ ___________________

_____ ______ ___________________
_____ ______ ___________________

_____ ______ ___________________

Type of Pack Made:

Consumer Packs: __________ Cartons:__________ 25# Sacks:__________ 50# Sacks:__________

(5’s, 10’s, 15’s, 20’s)

100# Sacks: ________ Tote Bins: __________ Bulk Loads: __________

Approximate packout per month (cwt):

_______ _______ _______ _______ _______ _______

January February March April May June

_______ _______ _______ _______ _______ _______

July August September October November December

Number of packers in area: _______________________

Location of nearest SWIS office: __________________

Approximate miles one way: ______________________

I, the undersigned applicant, agree to the following:

1. Comply with all the requirements of Marketing Order 946;

2. Promptly report all potatoes packed, shipped and marketed;

3. Promptly pay all inspection fees and assessments;

4. Apply annually for a renewal of permit;

5. Failure to comply with Marketing Order 946 may result in the cancellation of the Waiver permit.

6. Information provided is subject to verification by the SWPC and/or USDA.

____________________________________________________ ____________________

Signature of Applicant Date

Permission is hereby granted/denied to the above shipper for Modification of Inspection Privilege.

____________________________________________________ _____________________

Signature of Committee Chairman or Manager Date

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.

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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. 01/2014. Destroy previous editions.