QID 163922 Walnut Objective Measurement Survey - Permission Form

WALNUT OBJECTIVE MEASUREMENT SURVEY- PERMISSION FORM

(Cover sheet for permission form which
will be generated from a database.)

OMB No. 0535-0088
Approval Expires: ??/??/20??
Project Code: 758 QID: 163922
SMetaKey: 3922

United States
Department of
Agriculture
NATIONAL
AGRICULTURAL
STATISTICS
SERVICE
California Department
of Food and
Agriculture
USDA/NASS - California
Pacific Region
650 Capitol Mall, #6-100
Sacramento, CA 95814
Phone: 1-800-851-1127
Fax: 1-855-270-2722
Email: [email protected]

Please make corrections to name, address and ZIP Code, if necessary

The information you provide will be used for statistical purposes only. Your responses will be kept confidential and any person who willfully
discloses ANY identifiable information about you or your operation is subject to a jail term, a fine, or both. This survey is conducted in
accordance with the Confidential Information Protection provisions of Title V, Subtitle A, Public Law 107-347 and other applicable Federal
laws. For more information on how we protect your information please visit: https://www.nass.usda.gov/confidentiality. Response is
voluntary.
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 number is 0535-0218. The time required to
complete this information collection is estimated to average 15 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.
Recently, our office asked for information about the walnut acreage on your farming operation. That information appears in the attached
permission form. We are now collecting information to help determine walnut production in California. Response to this survey is voluntary,
however, we need and appreciate your cooperation. Any data reported by you or obtained from field observations will be kept confidential.

Please feel free to call the office at 1-800-815-1127 if you have any questions.

PRINTED - ??/??/??

ENTER NEW OPERATOR BELOW
NAME:
ADDRESS:
CITY:
ZIP:

<

ENTER NAME AND ADDRESS
CHANGES IN THE SPACES
PROVIDED.

>

PHONE:

PHONE:
999999999

PAGE 1
SEQUENCE - 1
ENTER NEW OWNER BELOW
NAME:
ADDRESS:
CITY:
ZIP:

PERMISSION AGREEMENT

OD: 99

AS: 12

PS:
CALIFORNIA
AGRICULTURAL STATISTICS
SERVICE

OPERATION NAME
OPERATOR NAME
OPERATOR ADDRESS
OPERATOR CITY, CA 99999
999-999-9999
- 999-999-9999

P.O. BOX 1258
SACRAMENTO, CA 95812
1-800-851-1127

Printed below is our record of crops on the parcel location shown below. Changes should be reported as follows:
REMOVALS: Line out; include date removed.
CORRECTION OF RECORDED ACREAGE OR VARIETY: Write "Correction" with the correct information.
ABANDONED ACRES NOT PULLED: Write "Abandoned".
CORRECTION OF PARCEL LOCATION: Line out and correct parcel location.
COUNTY

CROP

YEAR
PLANTED

VARIETY

PLANT
SPACING

NUMBER
TREES

ACRES

-- Permission Agreement -to the California Agricultural Statistics Service to send an
Permission is hereby GRANTED
NOT GRANTED
official sampler into the reported parcels operated by me for the purpose of counting and sizing a sample of fruit as part
of the crop forecast surveys.
Signature of Operator or Owner:

Title:

Will it be satisfactory for the official sampler to enter your parcel(s) in a properly identified vehicle without further contact
with you? YES
NO
Are there any locked gates on the parcel(s)?

YES

NO

Are there any dogs on the parcel(s)?

YES

NO

If you would like to be contacted or if there are any locked gates, whom should be contacted before entering the parcel(s)?
Name:
Title:
Phone: