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-STFO-1-00021

US CLASS Y WEIGHTS

NOT NEGOTIABLE

EXAMPLE ONLY – NOT FOR OFFICIAL USE
ISSUED AT:

Kansas City, KS
IDENTIFICATION:

LOCATION:

TM 761

Elavator X
Kansas City, KS

DATE OF SERVICE:

May 21, 2007
NET WEIGHT:

1 Carlot

TYPE OF MOVEMENT:

Local
START DATE:

START TIME:

FINISH TIME:

CLASS Y WEIGHING
KIND:

Sample grade for inspection

REMARKS:

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

APPLICANT NAME: Cargill, Inc.
SUPERVISING
OFFICE:

NAME OR SIGNATURE: Diane K. Palecek

FGIS - Stuttgart 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, 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 0580-0013. The time required to complete this information collection is estimated to average 42.084 hours 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.

EXAMPLE ONLY – NOT FOR OFFICIAL USE