FGIS-914 Submitted Sampe Inspection

FORM FGIS-914
JAN 07

Approved OMB No. 0580-0013

UNITED STATES DEPARTMENT OF AGRICULTURE
FEDERAL GRAIN INSPECTION SERVICE

U.S. GRAIN STANDARDS ACT
ORIGINAL

SUBMITTED SAMPLE INSPECTION

US-TOFO-1-09194

OFFICIAL PINK CERTIFICATE

NOT NEGOTIABLE

EXAMPLE ONLY – NOT FOR OFFICIAL USE
LEVEL OF INSPECTION:

ISSUED AT:

Original

DATE OF SERVICE:

Albany, NY

October 22, 2008

IDENTIFICATION:

BIN 23

NOT OFFICIALLY SAMPLED
KIND:
RESULTS:

Test Weight Per Bushel 58.5 lb/bu

Moisture 15.5 %

REMARKS:

The sample identification and inspection results shown on this certificate are assigned only to the quantity in the sample and not to any identified carrier, container, or lot from which the sample may have been taken. This certificate does not
meet the requirements of section 5 of the U.S. Grain Standards Act.
I CERTIFY THAT THE SERVICES SPECIFIED ABOVE WERE PERFORMED WITH THE RESULTS STATED.

APPLICANT NAME: Mundwiler Grain
ISSUING OFFICE:

NAME OR SIGNATURE:

FGIS - Toledo Field Office

This certificate is issued under the authority of the United States Grain Standards Act, as amended (7 U.S.C. 71 et seq.), and the regulations thereunder (7 CFR 800.0 et seq.). It is issued to show the kind, class, grade, quality, condition, or
quantity of grain; or the condition of a carrier or container for the storage or transportation of grain; or other facts relating to grain as determined by official personnel. The statements on the certificate are considered true at the time and place the
inspection or weighing service was performed. The certificate shall not be considered representative of the lot if the grain is transshipped or is otherwise transferred from the identified carrier or container or if grain or other material is added to or
removed from the total lot. If this certificate is not canceled by a superseding certificate, it is receivable by all officers and all courts of the United States as prima facie evidence of the truth of the facts stated therein. This certificate does not
excuse failure to comply with the provisions of the Federal Food, Drug, and Cosmetic Act or other Federal law.
WARNING: Any person who shall knowingly falsely make, issue, alter, forge, or counterfeit this certificate, or participate in any such actions, or otherwise violate provisions in the U.S. Grain Standards Act, the U.S. Warehouse
Act, or related Federal laws is subject to criminal, civil, and administrative penalties. The conduct of all services and the licensing of personnel under the regulations governing such services shall be accomplished without
discrimination as to race, color, religion, sex, national origin, age, or handicap.
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 0580-0013. The time required to complete this information collection is estimated to average 19.04 hours 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.

EXAMPLE ONLY – NOT FOR OFFICIAL USE