COC-155 (932) California Olives Special Purpose Shipment

OMB No. 0581-0178

CALIFORNIA OLIVE COMMITTEE

REPORT OF SPECIAL PURPOSE SHIPMENTS

20___ CROP YEAR

TO: California Olive Committee 770 E. Shaw Avenue, Suite 310 Fresno, CA 93710

FROM: EIN: _________________________________________

The above handler is requesting permission to package and market the following experimental shipments in order to conduct marketing research and development projects. For each application, the requesting handler must provide information including, but not limited to:

Purpose of Request:

Market Outlet:

Time Frame:

Place of Inspection: ________________________________ Anticipated Date of Pack: ____________________

Quantity	Variety(ies)	Fruit Size	Style	Type: Black/Green	Container Size	Can Code(s)	Type of flavoring; other amendments, etc

CERTIFICATION AND SIGNATURE: The undersigned, on behalf of the reporting handler, certifies to the California Olive Committee (COC) and the Secretary of Agriculture of the United States that the marketing order reporting requirements for receipt and disposition have been met; that all assessments under the marketing have been met; and that this fruit will be kept separate from other packaged olives by a means satisfactory to the inspection service.

______________________________________ ________________________________ _____________

Signature: Title: Date:

COC USE Inspection notified: __________________________________________________

ONLY Date: _____________________________________________________________

The following statements are made in accordance with the Privacy Act of 1974 (U.S.C. 552a) and the Paperwork Reduction Act of 1995, as amended. The authority for requesting the information to be supplied on this form is the Agricultural Marketing Agreement Act of 1937, Secs. 1-19, 48 Stat. 31, as amended, (7 U.S.C. 601-674). Furnishing the requested information is necessary for the administration of the marketing order program.

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 OMB 0581-0178. The time required to complete this information collection is estimated to average 20 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.

COC-155 (Rev. 01/2017) Destroy previous editions.