Form Fv-249 - Imported Pistachios - Failed Lot Notification printable pdf download

REPRODUCE LOCALLY – Include form number and date on all republications

OMB No. 0581-0215

USDA – Fruit and Vegetable Program

Marketing Order and Agreement Division

1400 Independence Avenue SW, Stop 0237

Washington, D.C. 20250-0237

Phone: (202) 720-2491; Fax: (202) 720-5698

Form FV-249 - Imported Pistachios - Failed Lot Notification

To be completed by the Aflatoxin Testing Laboratory. Provide the following information for the failed lot. Send

the original to the U.S. Customs and Border Protection office overseeing the importation of this lot, and send copies

to the importer and to the Marketing Order and Agreement Division within 10 days of test completion. Retain a

copy for your records.

Customs entry number:____________________________

Lot description: ______________________ Lot ID marks: ___________________________

Weight: _________________ Lbs. Container size/description: _______________________

Importer’s name: __________________________ Telephone:________________________

Address: ______________________ City:_____________ State:_____ Zip code:________

Sampled by: _____________________ Date: __________ Of (Agency) ________________

Aflatoxin certificate number: ________________________

Result for Test 1: __________________ Result for Test 2:___________________

Average result of Tests 1 and 2: ____________________

Signature: ______________________________________ Date: ________________________

Name of Laboratory/Company: ____________________________________________________

Address: ______________________ City: ____________ State: _____ Zip Code: __________

The making of any false statements or representations in any matter within the jurisdiction of any agency of the United States, knowing it to be

false, is a violation of Title 18, Section 1001, United States Code, which provides for a penalty of a fine for individuals and for organizations, or

imprisonment, or both.

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-

0278. The time required to complete this information collection is estimated to average 12 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 U.S. Department of Agriculture (USDA) prohibits discrimination in all 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, genetic information, political

beliefs, 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,

Director, Office of Civil Rights, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, or call (800) 795-3272 (voice) or (202) 720-

6382 (TDD). USDA is an equal opportunity provider and employer.

FV-249 (Rev. 05/2014. Destroy previous editions)

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Form Fv-249 - Imported Pistachios - Failed Lot Notification

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