No Form number (946) WA. Potatoes Inspection Certificate Failing M.O. R

OMB No. 0581-0178

S tate of Washington Potato Committee

P.O. Box 1815, Moses Lake, Washington 98837

Phone (509) 765-8845 / FAX (509) 765-4853

INSPECTION CERTIFICATE FAILING MARKETING ORDER 946 REQUIREMENTS

Shipper’s Name: ___________________________________ Shipper’s Special Purpose Certificate Number: _________________________

Shipping Point _____________________________________ Destination: ___________________________________________________

Date of Failed Inspection: ___________________ CWT Amount Failed: _______________ Variety: ________________________

TO COMPLY WITH FEDERAL MARKETING ORDER 946, PLEASE CHECK THE APPROPRIATE BOX AND FILL OUT THE REQUESTED INFORMATION.

Certificate Number	Federal/State Inspection Reason for Failing Marketing Order 946

• 1. If any of these potatoes were sent for processing, please list the following:

Processor’s name: ________________________________________________________________________________________________

Address: ______________________________________________________ State: __________________ Zip Code: _______________

Phone Number: ____________________________ CWT Shipped: ______________ Date of Shipment: ________________

• 2. If any of these potatoes were sent for animal feed, please list the following:

Name: __________________________________________________________________________________________________________

Address: ______________________________________________________ State: __________________ Zip Code: _______________

Phone Number: ____________________________ CWT Shipped: ______________ Date of Shipment: ________________

• 3. If any of these potatoes were sent to Charity, please list the following:

Charity name: ____________________________________________________________________________________________________

Address: ______________________________________________________ State: __________________ Zip Code: _______________

Phone Number: ____________________________ CWT Shipped: ______________ Date of Shipment: ________________

• 4. If any of these potatoes were re-run and re-inspected, please list the following:

Name of Packer/Shipper: _________________________________ Inspection Reference Number(s):_____________________________

Address: ______________________________________________________ State: __________________ Zip Code: _______________

Phone Number: ____________________________ CWT Shipped: ______________ Date of Inspection: ________________

Attach Copy of Passing Inspection Certificate(s).

I, the undersigned, a shipper responsible for the handling of the above potatoes, do hereby certify that the disposition shown for each lot above is the true disposition for each of these lots.

Title___________________________________________ Signature________________________________________________________________

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 0581-0178. The time required to complete this information collection is estimated to average 3 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.

(Exp. x/xxxx) Destroy previous editions.