Food Safety Destruction Certification Form
Complete this form to document and certify the destruction of food items that are unsafe, expired, contaminated, damaged, or otherwise approved for destruction.
Date of Destruction
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Location of Destruction
*
Name of Food Item
*
Description of Food Item (including batch/lot number if applicable)
*
Reason for Destruction
*
Please Select
Expired
Contaminated
Damaged
Unsafe for Consumption
Approved for Destruction
Other
Quantity Destroyed (specify units)
*
Method of Destruction
*
Please Select
Incineration
Landfill
Composting
Chemical Treatment
Other
Name of Responsible Person
*
First Name
Last Name
Witness Name (if applicable)
First Name
Last Name
Additional Notes or Comments
Submit Certification
Should be Empty: