FV-249 Imported Pistachios - Failed Lot Notification

REPRODUCE LOCALLY – Include form number and date on all republications

OMB No. 0581-0215

USDA – Fruit and Vegetable Program
Marketing Order and Agreement Division
1400 Independence Avenue SW, Stop 0237
Washington, D.C. 20250-0237
Phone: (202) 720-2491; Fax: (202) 720-5698

Form FV-249 - Imported Pistachios - Failed Lot Notification
To be completed by the Aflatoxin Testing Laboratory. Provide the following information for the failed lot. Send
the original to the U.S. Customs and Border Protection office overseeing the importation of this lot, and send copies
to the importer and to the Marketing Order and Agreement Division within 10 days of test completion. Retain a
copy for your records.

Customs entry number:____________________________
Lot description: ______________________ Lot ID marks: ___________________________
Weight: _________________ Lbs.

Container size/description: _______________________

Importer’s name: __________________________ Telephone:________________________
Address: ______________________ City:_____________ State:_____ Zip code:________
Sampled by: _____________________ Date: __________ Of (Agency) ________________
Aflatoxin certificate number: ________________________
Result for Test 1: __________________ Result for Test 2:___________________
Average result of Tests 1 and 2: ____________________

Signature: ______________________________________ Date: ________________________
Name of Laboratory/Company: ____________________________________________________
Address: ______________________ City: ____________ State: _____ Zip Code: __________
The making of any false statements or representations in any matter within the jurisdiction of any agency of the United States, knowing it to be
false, is a violation of Title 18, Section 1001, United States Code, which provides for a penalty of a fine for individuals and for organizations, or
imprisonment, or both.
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 05810278. The time required to complete this information collection is estimated to average 12 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) 7206382 (TDD). USDA is an equal opportunity provider and employer.
FV-249 (Rev. 05/2014. Destroy previous editions)

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