Reproduce Locally. Include form number and edition date on all reproductions Form Approved OMB No. 0581-0126 

U. S. DEPARTMENT OF AGRICULTURE 

AGRICULTURAL MARKETING SERVICE 

DAIRY PROGRAMS 

EQUIPMENT REVIEW REQUEST 

Applicant (Name and Address) 

Website 

Party Responsible for Payment if other 

than Applicant (Name and Address) 

Confirmation Required (Letter or Fax) 

Received 

Equipment Located at (Name and Address) 

Tax Identification No. (TIN) Tax Identification No. (TIN) Inspection Date(s) Requested:

Contact Contact Contact 

Telephone Telephone Telephone 

Fax Fax Fax 

Type of Equipment:  Dairy 

 Livestock and Poultry 

 3-A Third Party Verification 

Signature of Applicant (typed signature will suffice) Date Email 

 Domestic Inspection: 

A minimum of thirty (30) working days notification is required to insure specialists have ample time to make arrangements for the trip. If specialists are 

unavailable, the next available date acceptable to all parties will be assigned. 

 Foreign Inspection:

A minimum of forty-nine (49) working days advance notice is required for any foreign travel. The 49 days will start from the date this request form 

Is received by the Dairy Grading Branch. If specialists are unavailable, the next available date acceptable to all parties will be assigned. 

Hotel accommodations (USDA Dairy must pay): Best mode of transportation from airport (train, taxi, company pickup...): 

Does the Hotel accept Visa credit cards:  Yes  No 

If submitting electronically, please sign and mail or fax a copy of this form to the address below: 

 

USDA/AMS/DAIRY PROGRAMS 

Dairy Grading Branch 

Design Review Section 

Room 2746 – South Building 

1400 Independence Ave. SW STOP 0230 

Washington, DC 20250-0230 

Tel: 202 720-3171 

Fax: 202 720-2643 

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 0581-0126. The time required to complete this collection of information is estimated to average 3 minutes per person including time 

for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. 

 The U.S. Department of Agriculture (USDA) prohibits discrimination in all of its programs and activities on the basis of race, color, national origin, age, disability, and where applicable, sex (including gender 

 identity and expression), marital status, familial status, parental status, religion, sexual orientation, political beliefs, genetic information, reprisal, or because all or part of an individual's income is derived 

 from any public assistance program. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information 

 (Braille, large print, audiotape, etc.) should contact USDA's TARGET Center at (202) 720-2600 (voice and TDD). 

 

FOR OFFICIAL USE ONLY 

 Date Received: __________ 

 Date Assigned: __________ 

Specialist Assigned: __________ 

Project Number (s): __________ 

DA-162 (10-12)