FGIS 9601 Repair/Modication Notice

FORM APPROVED OMB NO. 0581-0309 (FGIS-9601)
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 0581-0309. The time required to complete this information collection is estimated to average 2 minutes per response
and 2 minutes of record keeping, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information.

U.S. DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE
FEDERAL GRAIN INSPECTION SERVICE
FIELD MANAGEMENT DIVISION

REPAIR/MODIFICATION NOTICE

SERIAL NUMBER (Optional)
_______________________________________________
NAME AND LOCATION OF FACILITY
_______________________________________________
DATE: ................

EMERGENCY BREAKDOWN

NON-EMERGENCY BREAKDOWN

..TIME:..

AM
PM

REQUESTED BY

PERSON NOTIFIED
MALFUNCTION NOTED

HANDLING/DELIVERY SYSTEM
SCALE(S) SYSTEM
GRAIN SPILLS(S)
REMARKS

ACTION TO BE TAKEN BY FGIS
UNTIL REPAIR OR MODIFICATION IS COMPLETED, WEIGHT CERTIFICATION:
WILL BE DISCONTINUED
WILL CONTINUE
WILL CONTINUE UNDER THE FOLLOWING CONDTIONS:

REPAIR/MODIFICATION COMPLETED
DATE

TIME

__________________________________________
(Name of Official Personnel)
FGIS-9601 (01/21) Previous editions are obsolete. Expires XX-XX

AM
PM

Instructions for Completing FGIS-9601
To complete the Repair/Modification Notice, enter the following information:
1.

Enter the scale serial number (optional).

2.

Enter the name and location of facility.

3.

Enter the date the form was prepared.

4.

Enter the time the form was prepared.

5.

Check block emergency breakdown or non-emergency breakdown.

6.

Enter the name of official personnel (Supervisor or Scales Specialist) requesting repair
or modification.

7.

Enter the name of elevator person notified.

8.

Check appropriate block to fit malfunction and explain in remarks what the malfunction
is and its location.

9.

Check appropriate block and explain the conditions under which weighing will continue.

10.

Enter the date of the completion of repair/modification.

11.

Enter the time the repair/modification was completed.

12.

Enter the name of the official inspection personnel who observed the completion of the
repair/modification.

Distribution. Complete the notice up to, and including, the “Action To Be Taken By FGIS” section.
Give the person notified of the necessary repairs or modifications a copy of the notice. After the
repairs or changes are made, complete the “Repair/Modification Completed” section of the notice and
send a copy to the field office.
Contact Information. Contact the field office responsible for the geographic area in which the service
is provided. Details for these locations can be found on the FGIS website.
For further information on the Repair/Modification Notice:
Joseph Han
Field Management Division
Policies, Procedures, and Market Analysis Branch
[email protected]