PMC 4.71A (993) CA Dried Prunes Users Receipt of Dried Undersized

OMB No. 0581-0178

PRUNE MARKETING COMMITTEE

3840 Rosin Court, Suite 170

Sacramento, CA 95834

USER’S RECEIPT OF DRIED UNDERSIZED PRUNES FOR NON-HUMAN USAGE

P-5 Inspection

Certificate No.: __________________________ Handler: _______________________________

The undersigned certifies to the United States Department of Agriculture (USDA) and to the Prune Marketing Committee (Committee) that the following described load of dried undersized prunes was received for non-human usage. The undersigned hereby agrees to permit access, by an authorized representative of the Committee or the USDA, to any plant or other facility where the dried undersized prunes received hereunder are stored or used, and to all books and records, during the usual business hours, pertaining to any undersized prune activity. Said books and records will be held for such inspection for a period of two years from the date of final usage of the undersized prunes.

Manifest or B/Lading No.

Net Prune Weight

Prunes to be Used for

Name of Trucking Co.

Date Received

Tractor License No.

Trailer License No.

_________________________________________________________________________________________

Location -Where truck unloaded: __________________________________________________________________

Name of firm receiving prunes: ___________________________________________________________________

Address of firm: _______________________________________________________________________________

Signature & Title: ______________________________________________________________________________

Date: _______________________________________

INSTRUCTIONS: Complete and return the original to the Committee. The Committee will forward a copy to your supplier. Also retain a copy for your records.

IMPORTANT NOTICE: This report is required by law (7 U.S.C. 608(d), 7CFR 993.50, 993.150(g)(2)(iii).

FAILURE TO REPORT can result in affine for each such violations and each day during which such violation continues shall be deemed a separate violation. The issuance of a false certificate knowing it to be false is a violation of title 18, section 1001 of the United States Code, which provides a penalty of a fine or imprisonment, or both.

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.

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.

PMC 4.71A (Exp. x/xxxx) Destroy previous editions.