DA-162 Equipment Review Request

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) Click here to enter text.		Party Responsible for Payment If other than Applicant (Name and Address) Confirmation Required (Letter or Fax) Received: ☐ Click here to enter text.						Equipment Located At (Name and Address) Click here to enter text.
Website Click here to enter text.
Tax Identification No. (TIN) Click here to enter text.		Tax Identification No. (TIN) Click here to enter text.						Inspection Date(s) Requested Click here to enter text.
Contact Click here to enter text.		Contact Click here to enter text.						Contact Click here to enter text.
Telephone Click here to enter text.		Telephone Click here to enter text.						Telephone Click here to enter text.
Fax Click here to enter text.		Fax Click here to enter text.						Fax Click here to enter text.
Type of Equipment: Click here to enter text.									☐ Dairy ☐ Livestock or Poultry ☐ 3-A Third Party Verification ☐ Appeal
Signature of Applicant (typed signature will suffice) Click here to enter text.			Date Click here to enter text.		Email
						Click here to enter text.
☐ 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 Click here to enter text.				Best mode of transportation from airport (train, taxi, company pick up, etc.): Click here to enter text.
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 collection is 0581-0126. The time required to complete this collection of information is estimated to average 10 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:				Specialist Assigned:
Date Assigned:				Project Number(s):
Form DA-162 (9-2015)