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pdfU.S. Department of Agriculture
AGRICULTURAL MARKETING SERVICE
FEDERAL GRAIN INSPECTION SERVICE
FORM APPROVED OMB NO. 0581-0309
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 1 hour 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.
QUESTIONNAIRE FOR PROPOSED
DIVERTER-TYPE MECHANICAL SAMPLER
Facility Name, City, State
Field Office
Kind of Elevator
Capacity
Authorization - Select All that Apply
Diverter
Non-diverter
In
Probe
Out
All Grains
Cargo
Small Grains
Barges
Hopper Cars
Coarse Grains - Not Corn
Carlots
Trucks
D/T Make and Model
S/N
General Location
Spout / Belt Name
Spout / Belt Angle
Belt Speed
Body Dimensions
Pelican Stroke
Pelican Opening
Grain Drop After Sampler (ft)
Access Safe
Inspection Door OK?
Power:
Air
Electric
Grain Drop Before Sampler (ft)
Spout
Yes
Verified No Auxilliary Controls
Yes
Location of Lockout OK?
No
Is Pelican Movement Steady?
Yes
Yes
Yes
No
LxW
Yes
No
Lights OK for Exams?
No
Does Pressure Return Promptly?
No
Spout / Belt Size
Belt
Yes
No
Air Pressure at Rest PSI
No
Timer Make and Model
Grain Flow Rate Past Sampler
Calculated Timer Setting
Secondary Make and Model
S/N
Delivery System
seconds
Grams per Sample
Gravity
Total No. of Samples
Quantity Adjustment Sealed?
Yes
Pneumatic
Delivery & Collection Box Secure?
No
Yes
Excess Returned to Lot?
No
Yes
No
Dust Control Locations
Weights:
GIPSA Class X
Number of Shipping Bins:
GIPSA Class Y
Depth (ft)
Certified
Other
Graded
Before or
Procedures to Stop Breakage:
After Release
Carrier I.D. by:
Radio
Visual
Other
Remarks/special restrictions when used to sample officially:
Signature of Official Personnel:
Date:
FORM FGIS-998 (01/21) Previous editions are obsolete. Expires XX-XX
CLEAR FORM
PRINT
U.S. Department of Agriculture
AGRICULTURAL MARKETING SERVICE
FEDERAL GRAIN INSPECTION SERVICE
FORM APPROVED OMB NO. 0581-0309
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 1 hour 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.
QUESTIONNAIRE FOR PROPOSED
DIVERTER-TYPE MECHANICAL SAMPLER
Facility Name, City, State
1
2
Field Office
Kind of Elevator
Capacity
3
4
Authorization - Select All that Apply
Diverter
Non-diverter
In
Out
D/T Make and Model
Cargo
6
14
Air
Electric
18
Grain Drop Before Sampler (ft)
Verified No Auxilliary Controls
22
Yes
25
Yes
5
All Grains
Hopper Cars
Spout
Belt
Belt Speed
Body Dimensions
15
Pelican Stroke
16
Pelican Opening
Grain Drop After Sampler (ft)
19
23
Yes
26
Yes
20
Yes
No
24
Yes
S/N
Delivery System
Dust Control Locations
39
29
30
32
Gravity
Quantity Adjustment Sealed?
Yes
Number of Shipping Bins:
41
seconds
33 Pneumatic
Delivery & Collection Box Secure?
No
GIPSA Class Y
Depth (ft)
37
Yes
No
Certified
42
Graded
Excess Returned to Lot?
38
Before or
Yes
40
Other
43
Radio
Visual
44
Procedures to Stop Breakage:
After Release
Other
Remarks/special restrictions when used to sample officially:
46
Signature of Official Personnel:
47
FORM FGIS-998 (01/21) Previous editions are obsolete. Expires XX-XX
34
Grams per Sample
45
Carrier I.D. by:
No
No
Weights:
GIPSA Class X
21
Yes
27
Secondary Make and Model
36
Inspection Door OK?
No
17
LxW
Air Pressure at Rest PSI
Calculated Timer Setting
35
13
Lights OK for Exams?
No
Does Pressure Return Promptly?
No
Access Safe
9
Spout / Belt Size
12
Grain Flow Rate Past Sampler
Total No. of Samples
8
Trucks
Spout / Belt Angle
Timer Make and Model
31
Carlots
11
Location of Lockout OK?
28
Coarse Grains - Not Corn
Spout / Belt Name
No
Is Pelican Movement Steady?
Small Grains
Barges
7
S/N
10
General Location
Power:
Probe
Date:
48
No
Instructions for Completing Questopmmaire
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
Facility name, city, and state.
Name of FGIS field office.
Check the box indicating kind of elevator.
Storage capacity of elevator.
Authorization Code-circle the numbers that apply to the intended sampler use.
Sampler Make & Model; e.g., Gamet 6800S.
Sampler Serial Number.
Is the sampler in a spout or on a belt end? For spout samplers-diameter or length x width cross sectional measurements or;
Belt Size-width and depth of grain carried.
General location of sampler; e.g., Headhouse 6th Floor; or Gallery.
Spout/belt name; e.g., Scale #1 lower garner.
Spout angle-90_ is vertical. Belt Angle-0_ is horizontal. Show normal angle and max/min limits of travel, if angle can be varied.
Belt speed-measure with belt loaded.
Check the box showing type of power.
Body dimensions for the sampler.
Pelican stroke is the distance traveled from one side to the other.
Length and width of the pelican opening.
Distance in feet from release point.
19.
Distance grain falls is used to estimate impact and breakage. For example, measure from sampler to bin bottom.
20.
Is access to the sampler by approved ladder or stairs, and does the platform have an approved railing?
21.
Are the inspection doors properly located on the sampler? Do they have appropriate seal hasps and hinges?
22.
Check verified after you determine that the system controls have no bypasses, dump counters, timer interrupts, or
programmable controllers.
23.
Location of lockout ok-does the lockout provided meet FGIS requirements?
24.
Light for examinations-can all exterior examination checks be made with lighting supplied?
25.
For pneumatic/hydraulic samplers-is pressure sufficient to move the pelican across the stream of grain evenly, without lagging or
slowing down.
26.
For pneumatic/hydraulic samplers-pressure returns to maximum before next cut is initiated.
27.
For pneumatic samplers-gauge pressure at rest. Maximum reached when no cuts are initiated.
28.
Timer Make & Model; e.g., Eagle HP5 Model 9.
29.
Flow past sampler should be figured out by timing a known amount, such as one scale draft, as it passes the sampler.
30.
Calculate the timer setting in seconds based on grain flow rate past sampler. Also show whether this is based on a 200, 350, or
500 bushel sampling rate.
31.
Secondary Sampler (divider) Make & Model; e.g., InterSystems MD300.
32.
Secondary Sampler Serial Number.
33.
Check box indicating type of sample delivery system.
34.
Weight in grams received for the official sample.
35.
Total number of samples needed for all interested parties.
36.
Are the quantity adjustment features on secondary sampler fixed or sealed in place?
37.
Is the sample delivery system secure from the air inlet to the collection box?
38.
Is excess grain automatically returned from the secondary to the lot from which the sample was taken?
39.
Location of dust collection ducts-are they located where they can affect the sample constituents? The measurements will serve
as a record of approved duct work.
40.
Weights-are weights official; i.e., supervised under the USGSA as Class X or Y-are weights Certified; i.e., supervised unofficially
by a local organization-or are weights unofficial and not supervised, or not provided?
41.
Shipping bins-number used.
42.
Shipping bin depth(s).
43.
Grading-will bin be held for grade or factor results before being released?
44.
Procedures to stop breakage-will the bins require use of cushion level indicators, grain ladders, or baffles to reduce impact of
grain and resulting breakage?
45.
Carrier identification or stowage locations.
46.
Special restrictions-any special procedural restrictions; e.g., weighback belt must be sealed, turnhead must be locked in
position, cushion must be maintained in shipping bin, etc.
47.
Name or signature of the official personnel who filled out the questionnaire.
48.
Date information obtained.
| File Type | application/pdf |
| File Title | FGIS 998 |
| File Modified | 2021-01-22 |
| File Created | 2018-04-12 |