CWB 24-15 Report of Substandard Walnuts Received (Non-Reserve Year

California Walnut Board OMB No. 0581‑0178

101 Parkshore Drive, Suite 250 CWB Form #24-15

Folsom, CA 95630 (Non-Reserve Year)

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 respectively certifies to the California Walnut Board and to the U.S. Department of Agriculture 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 California Walnut Board (CWB) following each delivery. Handlers will complete CWB Form #20, Report of Substandard Walnuts Delivered. The CWB 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, United States Code, which provides for the penalty of a fine of $250,000 for individuals and $500,000 for organizations or imprisonment of not more than five years, 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.

The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs, 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).

To file a complaint of discrimination, write to USDA, Director, Office of Civil Rights, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.

Rev. 04/09