CDAC SP-1 (987) CA Dates--Delivery Manifest

OMB No. 0581-0178

CALIFORNIA DATE ADMINISTRATIVE COMMITTEE

P.O. Box 1736

Indio, CA 92202-1736

Tel: (760) 347-4510 Fax: (760) 347-6374

DELIVERY MANIFEST

Growers and Handlers:

1. Account: _____________________________________________ Date of Loading: _______________________________

(Person or firm to receive payment for surplus covered by this manifest)

2. Location of Loading: _______________________________________________________________________________

(Where this load was picked up)

3. If field surplus, location by garden where grown: _________________________________________________________

4. Garden owned by: _________________________________________________________________________________

5. Loading:

Containers Dumped		Estimated Net Weight This Load
Type	Number

6. By: ______________________________________________________________________________

(Signature of person in charge of this loading)

Driver Information:

1. Name of Carrier: __________________________________________________________________________________

2. License Nos.: Truck: ________________________________ Trailer: ________________________________

3. If Surplus is dumped into bins, how many bins to this loading: _______________________________________________

The Surplus dates described herein subject to adjustment of weight in accordance with the weighmaster’s certificate were received on behalf of: ________________________________________________________________________________

(Name of firm purchasing the surplus dates)

Driver’s Signature: ______________________________________ Date: __________________________________

The making of a false statement or representation on this form, knowing it to be false, is a violation of title 18, section 1000 of the United States Code, which provides for the penalty of a fine or imprisonment, or both. This report is required by law (7 USC 608(d), 7 CFR 987.51, 987.151). Failure to report can result in a fine for each violation and each day during which such violation continues shall be deemed a separate violation.

INSTRUCTIONS:

Driver:

1. Request that the person in charge of this loading to complete the “Grower and Handler” section.

2. You complete the “Driver” section.

3. Give the DUPLICATE and TRIPLICATE copies to the person in charge of the loading.

4. Proceed to public weighmaster’s scale, weigh the load, and attach two copies of the weighmaster’s certificate to the ORIGINAL copy, and fax to the California Date Administrative Committee (Committee) within 24 hours of the surplus pickup from the grower or handler.

5. Retain the QUADRUPLICATE copy for your records.

Growers and Handlers:

1. The DUPLICATE copy is your record of surplus dates delivered to the Committee, who will mail you a receipt covering this load, showing the net poundage you have delivered as certified by the public weighmaster. If you do not receive the receipt within 7 days, notify the Committee. The TRIPLICATE copy is an extra copy for your records.

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 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.

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, gender identity (including gender expression), sexual orientation, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by program or incident.

Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the responsible Agency or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at http://www.ascr.usda.gov/complaint_filing_cust.html and at any USDA office or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: program.intake@usda.gov. USDA is an equal opportunity provider, employer, and lender.

CDAC-SP-1 (Exp. x/xxxx) Destroy previous editions.