WA-303 Original and/or Amendment Examination Report

This form is available electronically.

Form Approved – OMB No. 0560-0120 (See Page 2 for Privacy Act and Paperwork Reduction Act Statements.)

WA-303 (10-03-11)

U.S. DEPARTMENT OF AGRICULTURE Farm Service Agency

1. Code No.

     

2. License No.

3. Amendment No.

ORIGINAL AND/OR AMENDMENT EXAMINATION REPORT

     

     

4. THIS REPORT APPLIES TO:

A. Section      

B. Location (City, County, Parish and State)      

5. Applicant is:

6. Railroad Serving the Section

A. Owner or Lessee of Land

B. Owner or Lessee of Warehouse

     

7.

IF OWNER OF LAND, GIVE RECORDING OR TAX INFORMATION

A. Volume

B. Page

C. County

D. State

     

     

     

     

8. If Lessee of Land or Warehouse, give the following information (Note: Obtain a copy of all leases).

A. Lessor:      

B. Expiration Date (MM-DD-YYYY):      

9. Construction

A. Upright Warehouse

B. Flat Warehouse

C. Detached or Tanks

Concrete Metal Wood

Concrete Metal Wood

Concrete Metal Wood

10. Additional descriptive comments:

     

11. Handling Equipment

A. Type

B. No.

C. Cap. Per Hour Bu. Cwt.

D. Receiving (*)

E. Shipping (*)

F. Turning (*)

G. Scales (*)

H. Capacity

I. Upload (*)

J. Loadout (*)

Rail

Truck

Water

Rail

Truck

Water

LEG(S)

    

     

    

    

    

    

    

    

    

Truck

     

     

     

LEG(S)

    

     

    

    

    

    

    

    

    

Truck

     

     

     

LEG(S)

    

     

    

    

    

    

    

    

    

Hopper

     

     

     

LEG(S)

    

     

    

    

    

    

    

    

    

Hopper

     

     

     

Conveyor

    

     

    

    

    

    

    

    

    

Track

     

     

     

Dryer(s)

     

     

     

     

     

     

    

     

    

    

    

    

    

    

    

     

     

     

     

Cleaner(s)

     

* If none, state where weighed.

12. Portable Equipment

A. Type

B. Cap. Per Hour

C. Handling Capability Normal Workweek

D. Track Capacity (Number of cars that can be unloaded/loaded without switch)

Unload

Load Out

Bu. Cwt.

Bu. Cwt.

Bu. Cwt.

Auger

     

Rail Car

     

     

Car Dump

Cars

Pneumatic Loader

     

Truck

     

     

Front End Loader

     

Barge

     

     

Hopper Car Pit

Cars

     

     

Vessel

     

     

     

     

     

     

     

Hopper Car Spout

Cars

     

     

     

     

     

13. Is storage space equipped with:

Thermometer System: YES NO Aeration: YES NO Dust Collector: YES NO

14A. Agricultural Products will be stored: Bulk Bag Other (Specify:)

     

14B. Are eligible agricultural products now stored in this space? YES NO

15. Are agricultural products weighed by or under supervision of: Warehouse Operator FGIS Other Approved Agency (Name)

     

16. Are agricultural products graded by: Warehouse Operator FGIS FGIS Approved Agency Other

     

17. Is sufficient equipment available for grading products?

YES NO If “NO”, where are products graded?

     

WA-303 (10-03-11) Page 2
18. If the entire building is not to be included under license, the building must be properly partitioned. (Describe partition and materials used to construct it if applicable):
     
19. If products other than those to be included under license are to be stored or handled, name such products and comment on potential danger:
     
20. Does Warehouse Operator have complete control of warehouse space?		21. Is there any undue fire, flooding, or other hazard?
YES NO If “NO”, comment in Item 25 “Remarks.”		YES NO If “YES”, comment in Item 25 “Remarks.”
22. Are there any conditions hazardous to examiners?		23. Do you recommend issuance of a Warehouse Operator’s license?
YES NO If “YES”, comment in Item 25 “Remarks.”		YES NO If “NO”, comment in Item 25 “Remarks.”
24A. Signature of Examiner			24B. Date Signed (MM-DD-YYYY)
			     
25. Remarks:
     
NOTE:	The following statement is made in accordance with the Privacy Act of 1974 (5 U.S.C. 552a - as amended).  The authority for requesting the information identified on this form is 7 CFR Part 735, 7 CFR Part 1427, the United States Warehouse Act (Pub. L. 106-472), and the Commodity Credit Corporation Charter Act (15 U.S.C. 714 et seq.). The information will be used to determine whether licensee has required facilities and is operating in accordance with the United States Warehouse Act, regulations, or contractual requirements. The information collected on this form may be disclosed to other Federal, State, Local government agencies, Tribal agencies, and nongovernmental entities that have been authorized access to the information by statute or regulation and/or as described in applicable Routine Uses identified in the System of Records Notice for USDA/FSA-2, Farm Records File (Automated) and USDA/FSA-3, Consultants File.  Providing the requested information is voluntary.  However, failure to furnish the requested information will result in a determination of ineligibility to obtain new licensing or retain existing licensing under the United States Warehouse Act. 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 0560-0120. The time required to complete this information collection is estimated to average 30 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 provisions of appropriate criminal and civil fraud, privacy, and other statutes may be applicable to the information provided. RETURN THIS COMPLETED FORM TO THE KANSAS CITY COMMODITY OFFICE, WAREHOUSE LICENSE AND EXAMINATION DIVISION, STOP 9148, P.O. BOX 419205, KANSAS CITY, MO 64141-6205.

The U.S. Department of Agriculture (USDA) prohibits discrimination in all of 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, political beliefs, genetic information, 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, Assistant Secretary for Civil Rights, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, S.W., Stop 9410, Washington, DC  20250-9410, or call toll-free at (866) 632-9992 (English) or (800) 877-8339 (TDD) or (866) 377-8642 (English Federal-relay) or (800) 845-6136 (Spanish Federal-relay).  USDA is an equal opportunity provider and employer.