Ct Form Pesticide PDF Details

Pesticides are a necessary part of modern farming, but they also come with a number of drawbacks. One such drawback is the potential for chemical runoff to contaminate water supplies. To help mitigate this risk, the Connecticut Department of Energy and Environmental Protection has developed a new form for pesticides that will help farmers more efficiently apply these chemicals while minimizing potential water contamination. This form, known as Ct Form Pesticide, was created in collaboration with the United States Environmental Protection Agency and is now available for use by Connecticut farmers.

QuestionAnswer
Form NameCt Form Pesticide
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesdep rep 006, ct form pesticide, connecticut pesticide registration application 2020, application form ct radiology

Form Preview Example

Commercial Applicator Pesticide Use

 

DEEP USE ONLY

 

 

 

Summary Report

Date:

 

 

 

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:

 

 

Mailing Address:

 

 

City/Town:

State:

Zip Code:

Business Phone:

ext.

Fax:

*E-mail:

 

 

Supervisory Certification No.

Arborist Certification No.

Please check here if your home address has changed since your last submittal.

2. Name and Address of Business:

 

 

Mailing Address:

 

 

City/Town:

State:

Zip Code:

Business Phone:

ext.

Fax:

Contact Person:

Title:

 

*E-mail:

 

 

Please check here if your business address has changed since your last submittal.

*By providing this e-mail address you are agreeing to receive official correspondence from the department, at

this electronic address, concerning the subject application. Please remember to check your security settings to be sure you can receive e-mails from “ct.gov” addresses. Also, please notify the department if your e-mail

address changes.

Part II: Reporting Period

1.

This report covers the period from January 1,

 

to December 31,

 

 

2.

Check this box if pesticide usage by the above named supervisor has been reported by another Certified

 

Supervisor and provide that individual’s name and certification number.

 

Name:

 

 

Supervisory Certification No.

 

 

3.

Check this box if no pesticides were applied during the above reporting period. If so, you must still

 

complete and submit the remaining parts of this form, with the exception of Part IV.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DEP-PEST-REP-006

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Name of Certified Supervisor:

 

 

 

Certification No.:

Reporting Year:

Part III: Certified Applicator’s Information

 

 

 

 

 

 

 

 

 

 

 

Name of Certified Applicator

 

 

Certification No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Part IV: Commercial Pesticide Usage

 

 

 

 

 

 

 

Total Amount of Pesticide

 

 

 

 

 

 

 

 

 

 

 

 

 

EPA Product

 

 

 

 

 

 

 

 

 

Used

 

 

 

Pesticide Product Name

 

 

Registration

 

 

 

 

 

 

 

 

 

Before Diluting

 

 

 

 

 

 

No.

 

 

 

 

 

 

 

 

 

 

(check gals or lbs)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

gal or

lbs

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

gal or

lbs

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

gal or

lbs

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

gal or

lbs

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

gal or

lbs

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

gal or

lbs

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

gal or

lbs

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

gal or

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gal or

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gal or

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gal or

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gal or

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Check here if additional sheets are necessary. You may reproduce this sheet and attach the additional sheets to this sheet

DEP-PEST-REP-006

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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 22a-6 of the General Statutes, pursuant to Section 53a-157b of the

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 06106-5127

DEP-PEST-REP-006

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Rev. 10/12/12

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