OMB # 0581-0178

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State of Washington Potato Committee
P.O. Box 1815, Moses Lake, Washington 98837
Phone (509) 765-8845 / FAX (509) 765-4853
	


INSPECTION CERTIFICATE FAILING MARKETING ORDER 946 REQUIREMENTS 

Shipper’s Name: ___________________________________ 	Shipper’s Special Purpose Certificate Number: _________________________

Shipping Point _____________________________________ 	Destination: ___________________________________________________

Date of Failed Inspection: ___________________	CWT Amount Failed: _______________	Variety: ________________________

TO COMPLY WITH FEDERAL MARKETING ORDER 946, PLEASE CHECK THE APPROPRIATE BOX AND FILL OUT THE REQUESTED INFORMATION.

Certificate Number
Federal/State Inspection Reason for Failing Marketing Order 946


    • 1.	If any of these potatoes were sent for processing, please list the following:
Processor’s name: ________________________________________________________________________________________________
Address: ______________________________________________________	State: __________________	Zip Code: _______________
Phone Number: ____________________________	CWT Shipped: ______________	Date of Shipment: ________________
    • 2.  	If any of these potatoes were sent for animal feed, please list the following:
Name: __________________________________________________________________________________________________________
Address: ______________________________________________________	State: __________________	Zip Code: _______________
Phone Number: ____________________________	CWT Shipped: ______________	Date of Shipment: ________________
    • 3. 	If any of these potatoes were sent to Charity, please list the following:
Charity name: ____________________________________________________________________________________________________
Address: ______________________________________________________	State: __________________	Zip Code: _______________
Phone Number: ____________________________	CWT Shipped: ______________	Date of Shipment: ________________
    • 4.	If any of these potatoes were re-run and re-inspected, please list the following:
Name of Packer/Shipper: _________________________________	Inspection Reference Number(s):_____________________________
Address: ______________________________________________________	State: __________________	Zip Code: _______________
Phone Number: ____________________________	CWT Shipped: ______________	Date of Inspection: ________________
Attach Copy of Passing Inspection Certificate(s).
I, the undersigned, a shipper responsible for the handling of the above potatoes, do hereby certify that the disposition shown for each lot above is the true disposition for each of these lots.

Title___________________________________________	Signature________________________________________________________________

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