WA-221 Examination Report

Form Approved - OMB No. 0560-0120

This form is available electronically. (See Page 2 for Privacy Act and Paperwork Reduction Act Statements.)

WA-221 U.S. DEPARTMENT OF AGRICULTURE (10-31-11) Farm Service Agency EXAMINATION REPORT (Supplement 1)

1. NAME AND LOCATION OF WAREHOUSE      

2. LICENSE AND CODE NO.      

3. CUTOFF DATE (MM-DD-YYYY)     

A. RECORDS AND ACCOUNTS:

4. DESCRIBE THE SYSTEM OF ACCOUNTS AND STOCK RECORDS USED      

5A. IS A FIREPROOF SAFE, VAULT, OR COMPARTMENT PROVIDED FOR SAFEKEEPING OF RECEIPTS AND RECORDS? YES NO

5B. IF "NO", EXPLAIN     

B. FIRE-PROTECTION EQUIPMENT AND WAREHOUSE SECURITY:

6. DISTANCE TO NEAREST FIRE STATION      

7. WHAT IS THE SOURCE OF WATER SUPPLY?      

8. IF WATER SUPPLY IS FROM, OR SUPPLEMENTED BY, OTHER THAN CITY CONNECTIONS, EXPLAIN FULLY      

9. IS HYDRANT SYSTEM PROVIDED? YES NO

10. NUMBER OF HYDRANTS      

11. SIZE OF HYDRANTS      

12. LOCATION OF HYDRANTS      

13. ADEQUATE HOSE PROVIDED? YES NO

14A. DESCRIBE ANY ADDITIONAL FIRE PROTECTION EQUIPMENT INCLUDING PUBLIC FACILITIES      

14B. WATCHMAN SERVICE FIRE OTHER (Explain below:)

14C. IF WATCHLOCK USED

NO. STATIONS      

HOURLY HALF HOURLY

SECURITY

     

15A. IS THE WAREHOUSE PROPERTY ENCLOSED? YES NO

15B. IF "YES," HOW?      

16. IS A WRITTEN SECURITY PLAN IN PLACE THAT INCLUDES MEASURES TO PROTECT COTTON HANDLED AND STORED?

YES NO (IF “NO”, ISSUE WA-125)

17. HAS WAREHOUSE OPERATOR CONDUCTED A FACILITY VULNERABILITY ASSESSMENT AND ESTABLISHED PROCEDURES THAT ADDRESS (EACH OF THE FOLLOWING)? A. GENERAL SECURITY OF THE PHYSICAL STRUCTURES AND GROUNDS OF THE WAREHOUSE, B. SHIPPING AND RECEIVING PROCEDURES TO ENSURE THAT COTTON IS NOT SUBJECT TO TAMPERING, C. ACTION TO BE TAKEN IN THE EVENT OF A NATIONAL EMERGENCY, AND D. CONTACT INFORMATION FOR LOCAL SECURITY AUTHORITIES.

YES NO (IF “NO”, ISSUE WA-125)

C. SHIPPING FACILITIES:

18. RAILROAD SERVING WAREHOUSE      

19. WHAT OTHER SHIPPING FACILITIES ARE ACCESSIBLE?     

20. CAN THE WAREHOUSE OPERATOR LOAD OUT ACCORDING TO THE SHIPPING STANDARD? (If "NO", issue WA-125) YES NO

21. SIZE OF THE STAGING AND SHIPPING AREA      

D. HANDLING EQUIPMENT:

22. DESCRIBE THE EQUIPMENT FOR RECEIVING, STORING, AND DELIVERING THE PRODUCT      

23. NO. OF SCALES USED      

24. TYPE      

25. LOCATION      

26. HOW OFTEN TESTED?      

27. HOW TESTED?      

28. ARE TEST WEIGHTS AVAILABLE? YES NO

29. BY WHOM TESTED (Name or Title)?      

30. DESCRIBE SPACE OR CONTAINER PROVIDED FOR KEEPING LOOSE PRODUCTS OR SAMPLES      

31. DO YOU RECOMMEND ISSUANCE OF A WAREHOUSE OPERATOR'S LICENSE AND/OR APPROVAL FOR STORAGE OF GOVERNMENT LOAN OR OWNED COTTON? YES NO (IF “NO”, EXPLAIN FULLY ON WA-101)

All of the statements and answers on this and attached examination reports are true and correct to the best of my knowledge and belief.

32A. NUMBER OF ATTACHED WA-222's      

32B. DATE SIGNED (MM-DD-YYYY)      

32C. EXAMINER'S SIGNATURE

WA-221 (10-31-11) Page 2 of 2

NOTE:

The following statement is made in accordance with the Privacy Act of 1974 (5 U.S.C. 552a - as amended).  The authority for requesting the information identified on this form is 7 CFR Part 735, 7 CFR Part 1423, 7 CFR Part 1427, the United States Warehouse Act (Pub. L. 106-472), and the Commodity Credit Corporation Charter Act (15 U.S.C. 714 et seq.). The information will be used to determine whether licensee has required facilities and is operating in accordance with the United States Warehouse Act, regulations or contractual requirements. The information collected on this form may be disclosed to other Federal, State, Local government agencies, Tribal agencies, and nongovernmental entities that have been authorized access to the information by statute or regulation and/or as described in applicable Routine Uses identified in the System of Records Notice for USDA/FSA-2, Farm Records File (Automated) and USDA/FSA-3, Consultants File.  Providing the requested information is voluntary.  However, failure to furnish the requested information will result in a determination of ineligibility to obtain new licensing or retain existing licensing under the United States Warehouse Act. 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 0560-0120. The time required to complete this information collection is estimated to average 30 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 provisions of appropriate criminal and civil fraud, privacy, and other statutes may be applicable to the information provided. RETURN THIS COMPLETED FORM TO THE KANSAS CITY COMMODITY OFFICE, WAREHOUSE LICENSE AND EXAMINATION DIVISION, STOP 9148, P.O. BOX 419205, KANSAS CITY, MO 64141-6205.

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, 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). 

To file a complaint of discrimination, write to USDA, Assistant Secretary for Civil Rights, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, S.W., Stop 9410, Washington, DC  20250-9410, or call toll-free at (866) 632-9992 (English) or (800) 877-8339 (TDD) or (866) 377-8642 (English Federal-relay) or (800) 845-6136 (Spanish Federal-relay).  USDA is an equal opportunity provider and employer.