UTAH CROP IMPROVEMENT ASSOCIATION

SITE IDENTIFICATION LOG ADDENDUM

(Use when adding collectors to original log)

Species Common Name ___________________________________ Cert # ____________________

(Assigned by UCIA)

Seed Broker/Conditioner__________________________________ Conditioner Lot # ___________

1. Collector ________________________________ Field Lot # _______ Field Bulk Lb. ________

Tel. # __________________ Address ______________________________________________

Date(s) Collected _________ Date Deliv. ________ Site Map or GPS ¨ Dirt Sample ¨

Agency Permit # or Pvt. Landowner Name ____________________________________________

I attest that all the information provided is correct _______________________________________ Signature of Collector

2. Collector ________________________________ Field Lot # _______ Field Bulk Lb. ________

Tel. # __________________ Address ______________________________________________

Date(s) Collected _________ Date Deliv. ________ Site Map or GPS ¨ Dirt Sample ¨

Agency Permit # or Pvt. Landowner Name ____________________________________________

I attest that all the information provided is correct _______________________________________ Signature of Collector

3. Collector ________________________________ Field Lot # _______ Field Bulk Lb. ________

Tel. # __________________ Address ______________________________________________

Date(s) Collected _________ Date Deliv. ________ Site Map or GPS ¨ Dirt Sample ¨

Agency Permit # or Pvt. Landowner Name ____________________________________________

I attest that all the information provided is correct _______________________________________ Signature of Collector

4. Collector ________________________________ Field Lot # _______ Field Bulk Lb. ________

Tel. # __________________ Address ______________________________________________

Date(s) Collected _________ Date Deliv. ________ Site Map or GPS ¨ Dirt Sample ¨

Agency Permit # or Pvt. Landowner Name ____________________________________________

I attest that all the information provided is correct _______________________________________ Signature of Collector

5. Collector ________________________________ Field Lot # _______ Field Bulk Lb. ________

Tel. # __________________ Address ______________________________________________

Date(s) Collected _________ Date Deliv. ________ Site Map or GPS ¨ Dirt Sample ¨

Agency Permit # or Pvt. Landowner Name ____________________________________________

I attest that all the information provided is correct _______________________________________ Signature of Collector

ORIGINAL copy to UCIA – PHOTOCOPY for seed broker/conditioner records