CWB 24-15 (NRY) (984) CA Walnuts Rept. Substandard Walnuts Received (Non

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

REPORT OF SUBSTANDARD WALNUTS RECEIVED

This report of substandard walnuts received is submitted in compliance with the requirements of the Federal Marketing Order No. 984, as amended. In executing this form, the Substandard User 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 deliveries must be made to Approved Substandard Users.

2. Complete the information below.

3. Mail a copy of the form to the Board following each delivery. Handlers will complete Board Form 20, Report of Substandard Walnuts Delivered. The Board will match the forms to verify disposition of substandard walnuts.

DFA Inspection Certificate Number (if applicable)	Weighmaster Certificate Number (if available)	Net Weight

The above kernelweight of walnuts was delivered by:

Handler: ________________________________________ Delivery Date: ______________________________

Delivered to: Name of Approved User: ___________________________________________________

By: _____________________________ 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 or organizations 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 15 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.

CWB 24-15 (Exp. x/xxxx) Destroy previous editions.