WA-220 Examination Report

Form Approved - OMB No. 0581-0305

This form is available electronically. (See Page 2 for Privacy Act and Paperwork Reduction Act Statements.)

WA-220 (07-31-18)

U.S. DEPARTMENT OF AGRICULTURE Agricultural Marketing Service

1. CHECK ONE ORIGINAL SUBSEQUENT AMENDMENT

EXAMINATION REPORT

2. LICENSE AND CODE      

3. AMENDMENT      

4. DATE OF LICENSE (MM-DD-YYYY)      

5. CAPACITY      

6. LICENSE POSTED      

Examiner’s Check

7. NAME OF WAREHOUSE OPERATOR      

11. MAILING ADDRESS OF HEADQUARTERS OFFICE (Zip Code) (Include street address for express delivery)      

  

8. NAME OF WAREHOUSE      

12. LOCATON OF WAREHOUSE (City, County, Parish and State)      

  

9. MAILING ADDRESS OF WAREHOUSE (Including Zip Code)      

13A. TELEPHONE (Include Area Code)      

13B. FAX NO. (Include Area Code)      

  

10. PRINCIPAL PLACE OF BUSINESS      

13C. EMAIL ADDRESS (If Applicable)      

  

14. INDIVIDUAL IN CHARGE (HOME ADDRESS AND HOME TELEPHONE NUMBER (Include Area Code)      

  

15. TYPE OF BUSINESS ENTITY: Corporation Partnership Individual LLC

  

16. CORPORATION:

A. CHARTER EXPIRES (Date MM-DD-YYYY)      

B. FOREIGN CORPORATION PERMIT ISSUED BY State of      

C. PERMIT EXPIRES (Date MM-DD-YYYY)      

  

17. PARTNERSHIP (List names below if not shown above)

A. TYPE OF PARTNERSHIP (General, limited, etc.)      

  

B.      

C.      

D.      

  

E.      

F.      

G.      

  

18. INDIVIDUAL:

A. NAME      

B. HOME ADDRESS AND TELEPHONE NUMBER (Include Area Code)      

  

19. LIMITED LIABILITY COMPANY:

A. OPERATING AGREEMENT

B. ARTICLES OF ORGANIZATION

C. AUTHORIZED TITLES FOR SIGNATURES (If applicable)

D. AUTHORIZED BY Operating Agreement Articles of Organization

20. NAMES OF INDIVIDUALS AUTHORIZED TO SIGN WAREHOUSE RECEIPTS:

A

B

C

     

     

     

  

     

     

     

  

     

     

     

  

     

     

     

  

21. NAME OF ELECTRONIC WAREHOUSE RECEIPT PROVIDER      

22A. DOES WAREHOUSE OPERATOR BLOCK PILE? (If “YES”, go to Item 22B). YES NO

22B. IS WAREHOUSE OPERATOR AUTHORIZED TO BLOCK PILE? (If “NO”, Issue WA-125) YES NO

  

USDA is an equal opportunity provider, employer, and lender.

WA-220 (07-31-18) Page 2 of 2

23. OUTSTANDING LICENSES ISSUED TO SAMPLERS AND WEIGHERS (Federally Licensed Houses Only)						Examiner’s Check
A. NAME OF LICENSEE		B. SERVICE PERFORMED	C. LICENSE NO.		D. WHERE POSTED
     		     	     		     	  
     		     	     		     	  
     		     	     		     	  
     		     	     		     	  
     		     	     		     	  
     		     	     		     	 
     		     	     		     	  
24. STATE OTHER RELATED BUSINESS INTERESTS OF WAREHOUSE OPERATOR OR KEY PERSONNEL.      						  
25. GIVE NAMES AND LOCATIONS OF OTHER WAREHOUSES OPERATED BY WAREHOUSE OPERATOR NOT COVERED BY THIS LICENSE AND CODE IN THE SAME TOWN.      						  
26. STATE OPERATIONAL HOURS THAT THE WAREHOUSE IS OPEN EACH DAY - IF WAREHOUSE IS NOT TO BE OPEN EACH BUSINESS DAY, WHAT PROVISIONS HAVE BEEN MADE TO RECEIVE AND DELIVER COTTON?      						  
27. DOES WAREHOUSE OPERATOR HAVE ANY TYPE OF AGREEMENT WITH A FIELD WAREHOUSE COMPANY? IF "YES", HAS THIS BEEN CLEARED WITH USDA? IF "NO", FURNISH A COPY TO KCCO EXAMINER. YES NO						  
28. DOES WAREHOUSE OPERATOR ISSUE OPEN YARD OR EMERGENCY YARD RECEIPTS? YES NO				29. TOTAL OPEN YARD CAPACITY      		  
30A. EXAMINER'S INITIALS     				30B. DATE (MM-DD-YYYY)      		  
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 1423, 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 in determining an applicant’s eligibility for license. 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 0581-0305. The time required to complete this information collection is estimated 10 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 WAREHOUSE AND COMMODITY MANAGEMENT DIVISION, STOP 9148, P.O. BOX 419205, KANSAS CITY, MO 64141-6205.