TL Hemp Forms 08102026~2.docx

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Attached to
TL SG Hemp Forms 08102026
Solicitation number
BD-27-1002-1003-001-132254
Issued by
Massachusetts

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Massachusetts Department of Agricultural Resources Hemp Program 225 Turnpike Road; 3rd Floor, Southborough, MA 01772 Notice of Inspection

Licensee:
License No.:

MDAR Inspector(s) Present:

Additional Parties Present:

Date: / / at : am / pm

Address:
City/State:

Reason for Inspection

· Pre-Licensing

· Planting/Harvest

· Regulatory THC Sampling

· Record Keeping

· Routine

· Other

The undersigned hereby consents to an inspection of the premises indicated above by MDAR for the purpose of gathering records, samples, and any other information needed by MDAR pursuant to the USDA Final Rule, as applicable, M.G.L. c. 128, Sections 116 through 123, and the regulation promulgated thereunder at 330 CMR 32.00, Hemp Production.

Applicant Name (Print) Title

Applicant Signature Date

MDAR Inspector Signature Date

Massachusetts Department of Agricultural Resources Product Disposal Certificate 225 Turnpike Road; 3rd Floor, Southborough, MA 01772

Licensee Name:

License Type:
· Grower
· Processor
· Dual

License no.:

Additional Parties Present:

Inspector Name:
Date:
//
at
:
am/pm
Site Name:
Address:

Reason for Destruction: ☐Administrative Order ☐Voluntary ☐Other:

Product Name
Batch Number
Number of Units
Destruction Method

· Mix w/ Media ☐Burn ☐Compost ☐Other:

· Mix w/ Media ☐Burn ☐Compost ☐Other:

· Mix w/ Media ☐Burn ☐Compost ☐Other:

· Mix w/ Media ☐Burn ☐Compost ☐Other:

· Mix w/ Media ☐Burn ☐Compost ☐Other:

· Mix w/ Media ☐Burn ☐Compost ☐Other:

· Mix w/ Media ☐Burn ☐Compost ☐Other:

· Mix w/ Media ☐Burn ☐Compost ☐Other:

· Mix w/ Media ☐Burn ☐Compost ☐Other:

· Mix w/ Media ☐Burn ☐Compost ☐Other:

The destruction of hemp and/or hemp-derived products was executed by the undersigned licensee in the presence of the Massachusetts Department of Agricultural Resources in connection with the administration and enforcement M.G.L. c.128 §§116 through 123 and 7 CFR 990, when applicable. The undersigned acknowledges that the hemp and/or hemp-derived products have been rendered unusable and/or destroyed in accordance with the license issued by the Department and may not be sold or used for any purpose. The Licensee shall not receive any compensation or have a right to any recourse from the Massachusetts Department of Agricultural Resources. The Licensee waives any right to additional testing and appeal of this destruction. The Licensee also agrees to hold harmless and release the Commonwealth of Massachusetts, its agencies, officers, employees, contractors or agents from any and all claims, actions, suits, damages, judgments, attorneys’ fees, or prosecution of any kind, that may arise due to the voluntary destruction of hemp conducted in accordance with the Hemp Program administered by the Department of Agricultural Resources pursuant to M.G.L. c.128 §§116 through 123 and 7 CFR 990, when applicable.

Inspector Name:

Inspector Signature:
Date:

Name of Licensee:

Licensee Signature:
Date:

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