F/H form D(1) Hazelnuts Waste Product Control Rept.

HAZELNUT MARKETING BOARD
21595 A Dolores WayNE
Aurora, OR 97002-9738

FIR Form D(1)
OMB CONT. NO.
0581-0178

HAZELNUT WASTE PRODUCT CONTROL REPORT
INTENTION TO SHIP HAZELNUT WASTE
Notice is hereby given of intention to dispose of hazelnut waste and by-products as described below:
( ) Crushing for oil ( ) Blanks and shells ( ) Mixing into animal feed ( ) Other
Name and address of manufacturer, outlet, or other user

Number of pounds to be shipped

( ) raw or ( ) processed kernel weight.

Handler

Date

Signature
MANUFACTURER / USER CERTIFICATION

I hereby certify to the Hazelnut Marketing Board and the U.S. Secretary of Agriculture that we did
manufacture / use the hazelnuts described and identified below in the quantity and on the date specified. I
hereby agree that Board employees may enter our premises at any reasonable time to observe the storage or
disposition of the hazelnut material and to examine and audit our records of hazelnut transactions.
Weight Received
Pounds

Lot
Stamp No.

Date
Manuf/Used

Finished Product
Wght/Pounds

( ) Crushing for oil ( ) Blanks and shells ( ) Processed for animal feed ( ) Other
Manufacturer or User

Signature

Date

Note: The making of any false statement or representation on this torm. knowing it to be talse is a violation of Title 18. Section 10II. United
States Code. This report is required by law (7 U.S.C. 608(d). 7 C.F.R. 982.53). Failure to report can result in a fme of not less that $50 or more
than $500 for each such violation, and each day during such violation continues shall be deemed a separate violation.
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 irformation
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 5 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 '!finformation.
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, set; 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 derivedfrom 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.