FGIS 9601 Repair/Modication Notice

FORM APPROVED OMB NO. 0580-0013 (FGIS-9601)
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 0580-0013. The time required to complete this information
collection is estimated to average 2 minutes per response and 2 minutes of recordkeeping, including time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information.

SERIAL NUMBER (Optional)

U.S. DEPARTMENT OF AGRICULTURE
GRAIN INSPECTION, PACKERS AND
STOCKYARDS ADMINISTRATION
FEDERAL GRAIN INSPECTION SERVICE
FIELD MANAGEMENT DIVISION

NAME AND LOCATION OF FACILITY

REPAIR/MODIFICATION NOTICE

DATE

AM
PM

TIME

REQUESTED BY
EMERGENCY BREAKDOWN
NON-EMERGENCY BREAKDOWN

PERSON NOTIFIED

MALFUNCTION NOTED
HANDLING/DELIVERY SYSTEM

SCALE(S) SYSTEM

GRAIN SPILLS(S)
REMARKS:

ACTION TO BE TAKEN BY FGIS
UNTIL REPAIR OR MODIFICATION IS COMPLETED, WEIGHT CERTIFICATION:
WILL BE DISCONTINUED
WILL CONTINUE
WILL CONTINUE UNDER THE FOLLOWING CONDTIONS:

DATE

REPAIR/MODIFICATION COMPLETED
TIME

AM
PM

_____________________________________________
(Name of Official Personnel)
FGIS-9601 (6/04) (Replaces Form FGIS-9601, 9/92 which may be used). Expires January 2015

FORM APPROVED OMB NO. 0580-0013 (FGIS-9601)
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 0580-0013. The time required to complete this information
collection is estimated to average 2 minutes per response and 2 minutes of recordkeeping, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information.

U.S. DEPARTMENT OF AGRICULTURE
GRAIN INSPECTION, PACKERS AND
STOCKYARDS ADMINISTRATION
FEDERAL GRAIN INSPECTION SERVICE
FIELD MANAGEMENT DIVISION

REPAIR/MODIFICATION NOTICE

SERIAL NUMBER (Optional)

1.

NAME AND LOCATION OF FACILITY
2.

DATE

AM
PM

TIME

3.

4.

REQUESTED BY
6.

EMERGENCY BREAKDOWN
5.

NON-EMERGENCY BREAKDOWN

PERSON NOTIFIED
7.

MALFUNCTION NOTED
HANDLING/DELIVERY SYSTEM

SCALE(S) SYSTEM

8.

GRAIN SPILLS(S)
REMARKS:

ACTION TO BE TAKEN BY FGIS
UNTIL REPAIR OR MODIFICATION IS COMPLETED, WEIGHT CERTIFICATION:
WILL BE DISCONTINUED
9.

WILL CONTINUE
WILL CONTINUE UNDER THE FOLLOWING CONDTIONS:

DATE

10.

REPAIR/MODIFICATION COMPLETED
TIME
11.

12.

AM
PM

_____________________________________________
(Name of Official Personnel)

FGIS-9601 (6/04) (Replaces Form FGIS-9601, 9/92 which may be used). Expires January 2015

Instructions for Use. To complete the Repair/Modification Notice, enter the following
information:
1.

Enter the scale serial number (optional).

2.

Enter the name and location of facility.

3.

Enter the date the form was prepared.

4.

Enter the time the form was prepared.

5.

Check block - emergency breakdown or non-emergency breakdown.

6.

Enter the name of official personnel (Supervisor or Scales Specialist)
requesting repair or modification.

7.

Enter the name of elevator person notified.

8.

Check appropriate block to fit malfunction and explain in remarks what
the malfunction is and its location.

9.

Check appropriate block and explain the conditions under which
weighing will continue.

10.

Enter the date of the completion of repair/modification.

11.

Enter the time the repair/modification was completed.

12.

Enter the name of the official inspection personnel who observed the
completion of the repair/modification.

Distribution. Complete the notice up to, and including, the "Action To Be Taken By
FGIS" section. Give the person notified of the necessary repairs or modifications a copy
of the notice. After the repairs or changes are made, complete the "Repair/Modification
Completed" section of the notice and send a copy to the field office.

CONTACT INFORMATION:
Contact the field office responsible for the geographic area in which the service is provided. Details for
these locations can be found at:
http://www.gipsa.usda.gov/GIPSA/webapp?area=forms&subject=landing&topic=fgis
For further information on the Repair/Modification Notice:
Joseph Han
Policies, Procedures and Market Analysis Branch
Field Management Division
10383 N. Ambassador Drive
Kansas City, MO 64153
Telephone 816-659-8407
Fax 202-720-1015
joseph.d.han@usda.gov