KC334.pdf

PDF 2 MB Posted Jan 17, 2017

Attached to: Marine Cargo Surveys Federal contract opportunity
Solicitation number: 12-1NTS-17-S-0003
Issued by: Department of Agriculture Farm Service Agency Kansas City Commodity Office

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KC-334 Discharge/Delivery Survey Summary

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Other files for this federal contract opportunity

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File	Type	Posted
Request_for_Quotation_12-1NTS-17-S-0003-P0001.pdf	PDF	Jan 24, 2017
SF30_-_Amendment_to_Solicitation_12-1NTS-17-S-0003-P0001.pdf	PDF	Jan 24, 2017
Request_for_Quotation_12-1NTS-17-S-0003.pdf	PDF	Jan 17, 2017
KC334.pdf	PDF	Jan 17, 2017
kc337.pdf	PDF	Jan 17, 2017
Request_for_Quotation_12-1NTS-17-S-0003.pdf	PDF	Jan 17, 2017
kc337.pdf	PDF	Jan 17, 2017

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Preliminary/Final Discharge/Delivery Survey Summary (bid form for CCC contracted surveys) Orvilea 11.0.1.20130830.1.901444 See reverse side for Privacy Act, Public Burden and Nondiscrimination Statements.

Form Approved - OMB No. 0560-0177

KC-334

U.S. DEPARTMENT OF AGRICULTURE

(12-19-16) Farm Service Agency Preliminary Final (Check One)

DISCHARGE/DELIVERY SURVEY SUMMARY

(For CCC Contracted Surveys)

PAGE

REPORT NUMBER

SURVEY COMPANY NAME

NAME OF SUBCONTRACTOR

PERSON(S) WHO PERFORMED SURVEY

VESSEL NAME/VOYAGE #

FEEDER VESSEL/VOYAGE #

SHIPMENT INFORMATION

OCEAN BILL OF LADING #

COMMODITY PO #

DESTINATION COUNTRY/CITY

DISCHARGE PORT

VESSEL ARRIVAL DATE

VESSEL DISCHARGE COMMENCED/COMPLETED

DELIVERY TO FINAL DESTINATION COMMENCED/COMPLETED

ESTUFFING OF CONTAINERS COMMENCED/COMPLETED

COMMODITY/PACK SIZE

MANIFESTED UNITS

MANIFESTED WEIGHT (KGS)

SURVEY FINDINGS

DESCRIPTION

UNITS

ACCEPTED WEIGHT (Includes reconstituted/ sound KGS) WEIGHT LOSS IN KGS (Includes unfit losses) Quantity Discharged Sound Torn/Slack/Leaking Discharged Empty Wet/Moldy/Other Unfit Infested

TOTAL QUANTITY

DISCHARGED

Short Landed Excess Landed Sound/recovered Sweepings Additional Comments

PRINTED NAME OF PREPARER

PREPARER SIGNATURE

DATE

KC-334

(REVERSE)

Form Approved - OMB No. 0560-0177 (12-19-16)

PRIVACY ACT AND PUBLIC BURDEN STATEMENTS

The following statement is made in accordance with the Privacy Act of 1974 (5 USC 552a – as amended). The authority for requesting the information identified on this form is 7 CFR Part 1400, the Commodity Credit Corporation Charter Act (15 U.S.C. 714 et seq.), and the Agricultural Act of 2014 (Pub. L. 113-79). The information will be used to evaluate the CCC-contracted surveyor’s ability to submit bids to purchase processed commodities and provide services. 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-3, Consultants File. Providing the requested information is voluntary. However failure to furnish the requested information will result in a determination that the CCC-contracted surveyor is unable to submit bids to purchase processed commodities and provide services.

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 0560-0177. The time required to complete this information collection is estimated to average 3 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. Send comments regarding the burden estimate (or to reduce) or any other aspect of this collection to the U.S. Department of Agriculture, Kansas City Commodity Office (OMB No. 0560-0177), Chief, Business Operations Support Division, Stop 8768, P.O. Box 419205, Kansas City, Missouri 64141-6205.

NONDISCRIMINATION STATEMENT

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.

Check this block if Preliminary Discharge/Deliver Survey Summary (For Commodity Credit Corporation Contracted Surveys):

Check this block if Final Discharge/Delivery Survey Summary (For Commodity Credit Corporation Contracted Surveys):

Enter current page number of this report.:

Enter total number of pages prepared in this report.:

Enter your survey company name.:

Enter your subcontractor's name, if applicable.:

Enter the names of the person or persons who performed the survey.:

Enter the Commodity Credit Corporation reference number provided by Kansas City Commodity Office.:

Enter the vessel name and voyage number.:

Enter the names of the person or persons who performed the survey.:

Enter the destination country.:

Enter the discharge port or inland destination, as applicable.:

Enter the date the vessel arrived.:

Enter the date the vessel discharge commenced or completed, as applicable.:

Enter the date the delivery commended or completed, as applicable.:

Enter date destuffing of containers commenced or completed, as applicable.:

Enter the commodity and pack size.:

Enter the manifested units.:

Enter the manifested weight in kilograms or pounds.:

Enter a report number.:

Enter the number of sound units discharged.:

Enter the number of excess landed units.:

Enter the number of torn, slack, or leaking units.:

Enter the number of units discharged empty.:

Enter the number of wet units.:

Enter the number of infested units.:

Enter the total units discharged.:

Enter the number of short landed units.:

Enter the accepted weight of sound units discharged in kilograms or pounds. Includes reconstituted or sound.:

Enter the accepted weight of sweepings in kilograms or pounds. Includes reconstituted or sound.:

Enter the accepted weight of torn, slack or leaking units in kilograms or pounds. Includes reconstituted or sound.:

Enter the accepted weight of wet units in kilograms or pounds. Includes reconstituted/sound.:

Enter the accepted weight of infested units in kilograms or pounds. Includes reconsitututed or sound.:

Enter the total accepted weight in kilograms or pounds. Includes reconstituted or sound.:

Enter the accepted weight of excess landed units in kilograms or pounds. Includes reconstituted or sound.:

Enter the weight loss of torn, slack, or leaking units in kilograms or pounds. Includes unfit losses.:

Enter the weight loss of short landed units in kilograms or pounds. Includes unfit losses.:

Enter the weight loss of discharged empty units in kgs/lbs. Includes unfit losses.:

Enter the weight loss of wet units in kilograms or pounds. Includes unfit losses.:

Enter the weight loss of infested units in kilograms or pounds. Includes unfit losses.:

Enter the total weight loss in kilograms or pounds. Includes unfit losses.:

Enter any additional comments, as necessary.:

Enter the name of the preparer.:

Signature1:

Enter date form signed.:

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File details come from the government source that posted it. Updated Nov 14, 2017.