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 1^st 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 0581-0215. 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.

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, gender identity (including gender expression), sexual orientation, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by program or incident.

Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the responsible Agency or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English. To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at http://www.ascr.usda.gov/complaint_filing_cust.html and at any USDA office or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: [email protected]. USDA is an equal opportunity provider, employer, and lender.

ACP-5 (Rev. 05/2017. Destroy previous editions.)