FGIS 964 Supervision of Weight Certificate

FORM FGIS-964
JAN 07

Approved OMB No. 0580-0013

UNITED STATES DEPARTMENT OF AGRICULTURE
FEDERAL GRAIN INSPECTION SERVICE

U.S. GRAIN STANDARDS ACT
ORIGINAL

SUPERVISION OF GRAIN WEIGHT CERTIFICATE

US-NOFO-1-00339

US CLASS Y WEIGHTS

IDENTIFICATION:
SEE REMARKS

NOT NEGOTIABLE

ISSUED AT:
DESTREHAN, LA

DATE OF SERVICE:
January 31, 2007

LOCATION:
Elevator C
New Orleans, LA

NET WEIGHT:
800,000 Pounds

START TIME:
7:00

FINISH TIME:
7:30

TYPE OF MOVEMENT:
In
START DATE:
January 31, 2007

CLASS Y WEIGHING
KIND:

Corn

REMARKS:
TRNX3345, ACBS4545, USBB3389, BSBS0101

I CERTIFY THAT THE SERVICES SPECIFIED ABOVE WERE PERFORMED WITH THE RESULTS STATED.

APPLICANT NAME: Bulk Weighing Facility
SUPERVISING
OFFICE:

NAME OR SIGNATURE: Diane K Palecek

FGIS - New Orleans Field Office

THE CLASS Y GRAIN WEIGHTS INDICATED ON THIS CERTIFICATE WAS DETERMINED BY PERSONS EMPLOYED BY OR AT THE IDENTIFIED FACILITY WHO ARE OCCASIONALLY SUPERVISED BY THE SUPERVISING AGENCY.
THE SUPERVISING AGENCY DID NOT DETERMINE THE WEIGHT OF GRAIN IDENTIFIED ON THIS CERTIFICATE.
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, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information is 0580-0013. The time
required to disclose this recordkeeping requirement is to average 42.084 hours per recordkeeper annually, including the time to retain such records, and to notify, disclose, and report to third parties such recordkeeping requirements.