ACP-5 Minimal Testing Form

OMB No. 0581-0215
ADMINISTRATIVE COMMITTEE FOR PISTACHIOS
4938 East Yale Avenue, Suite 102, Fresno, CA 93727
Tel (559) 255-6480; Fax (559) 255-6485
Email: [email protected]

MINIMAL TESTING FORM
This form is submitted to the Administrative Committee for Pistachios (ACP) if you handle less than 1,000,000
pounds (assessed weight) of pistachios in a given production year. Upon approval of this form, the ACP will give
the handler the option of complying with section 983.53 of the Federal Marketing Order.
Section A: Handler must complete this form and mail to the ACP by August 1st prior to each production year. The
handler is responsible for retaining a copy of the completed form for their own records for 3 years following the
production year in which the pistachios were shipped.

Handler Name: ________________________________________________________________________
Address: ___________________________________City: _____________ State:____ Zip Code: ______
Assessed weight handled: ___________________________________________________________ Lbs.
Production Year: ______________________________________________________________________

Handler signature: ________________________________________ Date: _________________
Name: _________________________________________________ Title: _________________
Section B: To be completed by the ACP.

Approved / Denied By: ____________________________________________ Date: ________________
Name: __________________________________________________________Title: ________________

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 05810215. The time required to complete this information collection is estimated to average 6 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.

ACP-5 (Rev. 05/2014. Destroy previous editions.)