OMB No. 0581-0178

State of Colorado MO Docket A-4 (Exp. 3/31/2024) Destroy previous editions.

Colorado Potato Administrative Committee Phone: 970-352-5231

Area III - Northern Colorado Fax: 970-304-0861

P.O. Box 1774

Greeley, CO 80632

AREA III WAIVER OF INSPECTION - WEEKLY SHIPMENT REPORT

Dates: Week beginning _____________, and ending _____________ (inclusive)

To be submitted to the Colorado Potato Administrative Committee (Committee) at the close of business each Friday. 

(Duplicate copy to be retained by Handler.) If necessary, attach additional sheet to complete information.

Origin Report of Potatoes Handled - Received

Name, Address, Phone Quantity/Variety 

Received Carrier ID

Original Inspection 

Certificate No. and 

Date

Purpose *

*regrade, resort, and/or repack

Shipment Report of Potatoes Handled - Shipped

Name, Address, Phone Quantity in CWT. Type and Size of 

Container Carrier ID No.

__________________________________________ ___________________________________________________

Handler Address

__________________________________________ ___________________________________________________

Authorized Representative Phone and Fax Number

False certification, knowing it to be false, is a violation of title 18, section 1001, of the United States Code, among other statutes, which provide for a fine, 

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 9 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: program.intake@usda.gov. USDA is an equal opportunity provider, employer, 

and lender.