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

OMB No. 0581-0178

HAZELNUT MARKETING BOARD

21595-A Dolores Way NE

Aurora, OR 97002-9738

Tel: (503) 678-6823

Fax: (503) 678-6825

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 Signature Date

MANUFACTURER / USER CERTIFICATION

I hereby certify to the Hazelnut Marketing Board (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 Weight/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 form, knowing it to be false is a violation of title 18, section 1011 of the 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 fine 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 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 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 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.

F/H Form D(1) (Rev. 10/2010) Destroy previous editions.