STATE OF CALIFORNIA |
|
|
|
|
|
|
DEPARTMENT OF PESTICIDE REGULATION |
MONTHLY SUMMARY PESTICIDE USE REPORT |
|
|
|
|
ENFORCEMENT BRANCH |
|
|
|
|
|
DPR-ENF-060 (REV. 4-12) PAGE 1 OF 2 |
|
|
|
|
|
|
|
INSTRUCTIONS FOR COMPLETING THIS FORM ARE INDICATED BELOW AND ON THE REVERSE SIDE |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
OPERATOR (FIRM NAME) |
|
ADDRESS |
CITY |
|
ZIP CODE |
|
PHONE NUMBER |
|
|
|
|
|
|
|
|
|
OPERATOR ID/PERMIT NUMBER |
LICENSE NUMBER |
|
COUNTY WHERE APPLIED |
COUNTY NUMBER |
MONTH/YEAR OF USE |
|
TOTAL NUMBER OF APPLICATIONS |
|
|
|
|
|
|
|
|
|
1.Complete Columns A, B, C, and D for All Users
2.Complete Column E by using one of the following codes:
Code 10 |
- |
Structural Pest Control |
includes any pest control work performed within or on buildings and other structures. |
Code 30 - Landscape Maintenance Pest Control |
includes any pest control work performed on landscape plantings around residences or other buildings, golf courses, parks, cemeteries, etc. |
Code 40 |
- |
Right-of-Way Pest Control |
includes any pest control work performed along roadsides, power lines, median strips, ditch banks, and similar sites. |
Code 50 |
- |
Public Health Pest Control |
includes any pest control work performed by or under contract with State or local public health or vector control agencies. |
Code 80 |
- |
Vertebrate Pest Control |
includes any vertebrate pest control work performed by public agencies or work under the supervision of the State or county agricultural commissioner. |
Code 91 - Commodity Fumigation (Nonfood/Nonfeed) |
includes fumigation of nonfood/nonfeed commodities such as pallets, dunnage, furniture, burlap bags, etc. |
Code 100 |
|
- Regulatory Pest Control |
includes any pest control work performed by public employees or contractors in the control of regulated pests. |
3. Complete Columns F and G, if use does not fit one of the above codes |
|
A |
|
B |
|
|
C |
|
|
D |
|
E |
F |
|
G |
|
|
|
|
|
|
|
|
|
|
|
|
|
MANUFACTURER AND |
|
EPA/CALIFORNIA REGISTRATION NUMBER FROM LABEL |
TOTAL PRODUCT USED |
NUMBER OF |
|
CODE |
COMMODITY OR SITE |
|
ACRES/UNITS |
|
NAME OF PRODUCT APPLIED |
|
INCLUDE ALPHA CODE |
(Check One Unit of Measure) |
APPLICATIONS |
|
TREATED |
|
TREATED |
|
|
|
|
|
|
|
|
|
LB |
OZ |
PT |
QT |
GA |
|
|
|
|
|
|
|
|
|
|
|
LB |
OZ |
PT |
QT |
GA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
LB |
OZ |
PT |
QT |
GA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
LB |
OZ |
PT |
QT |
GA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
LB |
OZ |
PT |
QT |
GA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
LB |
OZ |
PT |
QT |
GA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
LB OZ PT QT GA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
REPORT PREPARED BY |
|
|
|
|
|
|
|
|
DATE |
|
|
|
|
|
|
Distribution: CAC - Two copies; Report preparer - One copy
GENERAL INFORMATION FOR COMPLETING THE MONTHLY SUMMARY PESTICIDE USE REPORT
(Page 2 of 2)
Reporting Requirements
Reporting of all pesticide applications including spray adjuvants and plant growth regulators, is required by:
1.Landscape maintenance gardener pest control businesses, agricultural pest control businesses performing residential work, and structural pest control businesses.
2.Public agencies, pest control businesses and property operators who apply pesticides for agricultural use other than for the production of an agricultural commodity. These uses include applications for the production of poultry, fish, and apiary. Pest control businesses must report uses for the production of livestock. Also, uses on golf courses, parks, rights-of-way, cemeteries, forests, ditches, fence lines, etc. must be reported.
3.Persons who use restricted materials for uses other than the production of an agricultural commodity.
4.Persons who use a pesticide for industrial post-harvest commodity treatments.
5.Persons who use a Ground Water Protection pesticide, listed in Title 3, California Code of Regulations, section 6800(b) for any outdoor, institutional or industrial use.
Report Filing Deadlines
Submit two (2) copies of this report to the county agricultural commissioner by the 10th of the month, following the month in which the work was performed. Reports may be hand-delivered or mailed, the postmark serving as the date of delivery. Retain a copy for your records.
For each month when no pest control work has been performed, licensed pest control businesses must submit a use report by the 10th day of the following month to the county agricultural commissioner in counties where they are registered. The use report must indicate that no pest control work was performed.
SPECIFIC INSTRUCTIONS FOR COMPLETING THE FACE PAGE
The operator/firm information should be filled out completely, including the address, ZIP code, and telephone number.
Identify the Operator Identification/Restricted Material Permit Number, if applicable.
Enter the name of the county where the pesticide(s) was applied.
Indicate the county number where the product(s) was applied. The county number is available from the county agricultural commissioner's office. A separate report must be filed for each county where pesticides were applied.
Enter the month and year in which the applications were made.
Enter the total number of applications (i.e., the total of column D below) made during the month.
In Column A, enter both the manufacturer and brand name of the product.
In Column B, enter the "EPA Registration Number" or "California Registration Number" that appears on the pesticide label, including alpha codes, if any (AA, ZA, ZB, etc.). Do not use the "EPA Establishment Number" (Est. No.).
In Column C, indicate the total amount of product used as formulated and packaged by the manufacturer. Do not report the total mixture after dilution. Check only one unit of measure. If necessary, decimals and fractions may be used.
In Column D, indicate the total number of applications for each pesticide used during the reporting month. Each separate site (home, apartment complex, building, right-of-way, grain silo, etc.) should be counted as one application. For tank mixes, each represented pesticide should be credited with one application.
In Column E, if the use of the product is structural, landscape, right-of-way, vertebrate, public health, commodity fumigation (nonfood/nonfeed) or regulatory, enter the appropriate code number. Leave Columns F and G blank.
In Column F, if use of the product is not included in one of the number coded categories that are identified in column E, such as food/feed commodity fumigations, seed treatment, noncrop fencelines or ditch banks, etc., enter the commodity or site treated. Leave Column E blank.
Do not enter vertebrate pest control work in production areas such as orchards or other crop areas. This work should be reported on the Production Agriculture Monthly Pesticide Use Report.
In Column G, if use of the product is not included in one of the number-coded categories that are identified in Column E, enter the amount treated and the appropriate unit of measure (acres, pounds, square feet, tons, etc.). If you have a different measure, describe it fully and enter the amount treated. Leave Column E blank.
Enter the name of the person responsible for completing the information, and date the report. This could be a licensee, a manager, the person who applied the pesticide, a bookkeeper, etc.
