F/H form D(1) (982) 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 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.

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.

F/H Form D(1) (Exp. x/xxxx) Destroy previous editions.