DA-162 Equipment Review Request

Reproduce Locally. Include form number and edition date on all reproductions
U. S. DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE
DAIRY PROGRAMS

Form Approved OMB No. 0581-0126

EQUIPMENT REVIEW REQUEST
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

Applicant (Name and Address)

Website

Review for:

Type of Equipment:

Signature of Applicant (typed signature will suffice)

Date

†
†
†

Dairy
Livestock and Poultry
3-A Third Party Verification

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):
Does the Hotel accept Visa credit cards: † Yes † No

Best mode of transportation from airport (train, taxi, company pickup…):

Mail or Fax this form for All Reviews to:
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

esign Review Section

Date Received: __________

Specialist Assigned: __________

Date Assigned: __________

Project Number (s): __________

DA-162 (08-12) Destroy previous editions.