Understanding the components of the Connecticut Pesticide Form, officially known as the Commercial Applicator Pesticide Use Summary Report, is crucial for those involved in the application of pesticides within the state. This meticulous document, designed for regulatory compliance and oversight by the Department of Energy and Environmental Protection (DEEP), serves multiple functions. It requires the detailed reporting of pesticide application activities conducted over the previous calendar year, underlining the state's commitment to environmental stewardship and public health. At its core, the form captures essential information about the certified supervisor responsible for pesticide application, including their name, contact details, and certification numbers. This accountability is deepened through a section dedicated to the business's address and contact person, ensuring a clear line of responsibility. The form also covers the reporting period, specifying that all activities within the January 1 to December 31 timeframe must be disclosed by January 31 of the following year. Moreover, it allows for the declaration of no pesticide usage within the reporting period, still requiring submission to uphold transparency. In documenting specifics of pesticide usage, such as product names, EPA registration numbers, and quantities used, the form emphasizes the importance of accurate record-keeping in safeguarding environmental and public health. A final certificate of accuracy, signed by the certified supervisor, attests to the truthful and complete nature of the information provided, highlighting the legal and ethical obligations of pesticide applicators. As such, this form not only facilitates regulatory compliance but also reinforces the collective responsibility towards sustainable pesticide management.
| Question | Answer |
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| Form Name | Ct Form Pesticide |
| Form Length | 3 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 45 sec |
| Other names | dep rep 006, ct form pesticide, connecticut pesticide registration application 2020, application form ct radiology |
Commercial Applicator Pesticide Use |
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DEEP USE ONLY |
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Summary Report |
Date: |
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Print in ink or type unless otherwise noted. Retain a copy for your records.
This form must be submitted on or before January 31st for pesticide applications made during the preceding calendar year.
Part I: Pesticide Certified Supervisor Information
1. Name of Certified Supervisor: |
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Mailing Address: |
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City/Town: |
State: |
Zip Code: |
Business Phone: |
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Fax: |
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Supervisory Certification No. |
Arborist Certification No. |
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Please check here if your home address has changed since your last submittal. |
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2. Name and Address of Business: |
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Mailing Address: |
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City/Town: |
State: |
Zip Code: |
Business Phone: |
ext. |
Fax: |
Contact Person: |
Title: |
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Please check here if your business address has changed since your last submittal. |
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*By providing this
this electronic address, concerning the subject application. Please remember to check your security settings to be sure you can receive
address changes.
Part II: Reporting Period
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This report covers the period from January 1, |
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to December 31, |
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2. |
Check this box if pesticide usage by the above named supervisor has been reported by another Certified |
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Supervisor and provide that individual’s name and certification number. |
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Name: |
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Supervisory Certification No. |
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3. |
Check this box if no pesticides were applied during the above reporting period. If so, you must still |
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complete and submit the remaining parts of this form, with the exception of Part IV. |
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Name of Certified Supervisor: |
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Certification No.: |
Reporting Year: |
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Part III: Certified Applicator’s Information |
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Name of Certified Applicator |
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Certification No. |
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Part IV: Commercial Pesticide Usage
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Total Amount of Pesticide |
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EPA Product |
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Used |
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Pesticide Product Name |
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Registration |
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Before Diluting |
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(check gals or lbs) |
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Check here if additional sheets are necessary. You may reproduce this sheet and attach the additional sheets to this sheet
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Rev. 10/12/12 |
Part V: Certification of Accuracy
“I have personally examined and am familiar with the information submitted in this document and all attachments thereto, and I certify that based on reasonable investigation, including my inquiry of those individuals responsible for obtaining the information, the submitted information is true, accurate and complete to the best of my knowledge and belief. I understand that a false statement in the submitted information may be punishable as a criminal offense, in accordance with Section
General Statutes, and in accordance with any other applicable statute.”
Signature of Certified Supervisor |
Date |
Printed Name of Certified Supervisor |
Title |
Mail completed Commercial Applicator Pesticide Use Summary Report to:
PESTICIDE MANAGEMENT PROGRAM ENGINEERING AND ENFORCEMENT DIVISION
BUREAU OF MATERIALS MANAGEMENT AND COMPLIANCE ASSURANCE DEPARTMENT OF ENERGY AND ENVIRONMENTAL PROTECTION
79 ELM STREET HARTFORD, CT
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