FV-192 Date Form No. 2

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r

u... DEPARn8I' 011AGIICUL1\IM
AGRICULTURAl. MAllKET1NG SERViCI
FRUIT AND VEGETAILI! PR()GRAU8

AhIbito

ontheboIoI,
of_.

-.18IaIon.

_ITS.)Per80n8

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color.__

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odgIn,""'" cll8I>iIIy.
ond-. """,,_.
poIIIc:8I
boI8fs,
or

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1or_of___~.lorgoprirt.

MdoI8pe. )conI8ctUSDA',TARGET
C8rUr",(202)T.II).28OI)
(wic88ftdTOO).To'" 1 __
_10 USDA,
~.OIIo801CM1RJstD.I_
~
S.W..V\/8oHngIan,
D.C.~10.
~
(wic8).. (2112)
7'2G«382
(TDD~
USDA
II..,
~
8ftd
,.,.

may result iilfiDe

dII111m (5) years. or bod1(18 V.S.C. 1001).

of_

mole dJID

$10,om

,toII

of..-on,
,
(800)

or mpriSODIDeut
for DOtmom

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I BEREBY CBRTDT to Ibe U.S. DepubDeIItof Apicu1tunItba&I flaveacqufnd Ibe daI8Icoveredby dda cerdftcadoa; 1haII wiDuse or soildiem for use oDl)"iD
.
bakery. c:on1'ecdoDeIY.
or other prodw:tau pen11i1mdby
Ibe RepJetiaDGoveruiDaIbe ImporIadoDofDaml(7 cPa 999.1); IDdtba&1am:(au"..)

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PROCESSOR
((hM of d.t.. foIpr«:euIngJ
1. DATEOfPURCHASI'

0

RESELLER",..,
In.,.. ,., ~J

2. PLAC!OFPURCHAS&
1CJt'f..__

3. NAMEANDADDRESS OFIMPORTEROR sa.LiR

4. DATES ACQUIRED:
TOTAL NET WEIGHT
(lb.1

NO. OF CONTAINERS

DATI!

NAME

AND ADDRESS

OF FIRM

SIGNATURE

TITLE

FV-192

18-00) fo..tnr(

ptev#tM18
.mtonJ

TOTAL NET WEIGHT
(IbJ

NO. OF CONTAINERS

OF AUTHORIZED

OFFICIAL