CWB 24-05 (NRY) (984) CA Walnuts Application for Approved User of Substa

OMB No. 0581-0178

California Walnut Board

101 Parkshore Drive, Suite 250 (Non-Reserve Year)

Folsom, CA 95630

Ph (916) 932-7070; Fax (916) 932-7071

APPLICATION TO BE AN APPROVED USER OF

SUBSTANDARD WALNUTS

This application to be an approved user of substandard walnuts is submitted in compliance with the requirements of the Federal Marketing Order No. 984, as amended. In executing this form, the Substandard User respectively certifies to the California Walnut Board (Board) and to the U.S. Department of Agriculture (USDA) as to the correctness and completeness of their statement.

Instructions: 1. All substandard users must complete the application to be an approved user.

2. Mailed a signed original to the Board.

3. The application will be reviewed by the Board. If approved, your company will be sent a confirmation and listed as an Approved Substandard User.

Application is hereby made for designation as an approved user of substandard walnuts with the privilege of receiving substandard walnuts for such use, or uses, as designated below, as provided in Section 984.464 of Marketing Order No. 984, as amended.

□ crush for walnut oil □ manufacture livestock feed □ feeding directly to livestock

In consideration of the granting of this approval, the undersigned agrees to:

1. Use such substandard walnuts as received for no other purpose than as designated above.

2. Store and manufacture such substandard walnuts as received only at the location or locations specified.

3. Permit inspection of such storage and manufacturing facilities and of substandard walnuts received and held and examination of books and records covering the walnut transactions by the Board and USDA.

4. Keep written records of receipts which will show the names and addresses of persons from whom walnuts were acquired and make such records available for examination by authorized representatives of the Board and USDA during regular business hours, for the period of two years after the end of the marketing year in which the recorded transactions were completed.

5. Agree to negotiate with the handler a fair price for all substandard material received.

Manufacturing operations are conducted at: ______________________________________________________

_____________________________________________________________________________________________

Prior to disposition, substandard walnuts will be stored at: __________________________________________

_____________________________________________________________________________________________

Our daily maximum manufacturing capacity of substandard walnuts is: __________________________________

_____________________________________________________________________________________________

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 5 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.

I hereby certify that substandard walnuts received will only be used for the use designated above and will not be disposed of in any other form.

By: ____________________________________________ Date: ______________________________________

Title: ___________________________________________ Firm Name: ________________________________

Address: ________________________________________ Phone No. __________________________________

________________________________________________ Fax No. ____________________________________

Application is hereby approved, subject to revocation for cause:

CALIFORNIA WALNUT BOARD

By: ____________________________________________ Date: ______________________________________

Title: __________________________________________

The making of any false statements or representations in any matter within the jurisdiction of any agency of the United States, knowing it to be false, is a violation of title 18, section 1001, of the United States Code, which provides for the penalty of a fine for individuals and for organizations or imprisonment, or both. No walnut handler shall dispose of substandard walnuts until this application has been received and approved by the Board (7CFR 984.64 and 7CFR 984.464).

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.

CWB 24-05 (Exp. x/xxxx) Destroy previous editions.