Dpr Form 39 030 – Fill Out and Use This PDF

1.	Firm Name
2.	Mailing Address of Firm	Check box if new address	City	State	Zip Code
3.	Street Address (if different from above) or Agent Address		City	State	Zip Code
4.	Name of Authorized Representative
5.	Telephone Number of Representative	6. Fax Number	7. E-mail Address
	( )	( )

8.Product Brand Name (exactly as shown on label)

9. U.S.EPA Registration Number		10. Product Composition Statement- Attached is either
			Product Formulation Information form (Page 3), or
			U.S. EPA Confidential Statement of Formula
11.	Type of California registration action requested	12.	Type of U.S. EPA registration
	New Product		Section 3
	Additional Brand Name		Supplemental Registration of Distributor (Subregistration)
	Change of Company Ownership		Section 5 (Experimental Use Permit)
	Change of Company Name Only
	Alternate Formula		Concurrent Submission Allowed
	Revised Formula		Not Required, California-Only Registration
	Interim Registration (FAC 13161)
	Section 24c (Full Product)
	Other (attach cover letter)
13.	Container Type(s), Composition(s) and Size(s)	14.	Density:
			Liquid Product = _____________Lbs. per Gallon
			or
			Solid Product = _____________Lbs. per Cubic Foot

I certify, under penalty of perjury, that all information submitted on this application for registration is accurate and complete.

X_____________________________________ / _____________________________________________/ ____________________

Signature of Authorized Representative

Type or Print Name/Title

Date Signed

Information about your product and its intended uses is required to allow DPR to correctly process and prepare notices for this application.

1.Type of pesticide - Check one or more of the following boxes:

2.Application methods - Check one or more of the following boxes:

	Ant/Wasp/Rodent Mound	Dust	Smoke	Wash, Soak, Dip
	Additive	Evaporating Solid	Soil Applied (inject, shank,	or Mop
	Attached (e.g. collar/	Filtration System	chisel, or work into soil)	Water Application
	eartag)	Fog	Spray	Wick Applicator
	Bait	Fumigation	Topically Applied
			(rub on)	Other (specify):
	Broadcast
		Injection
			Trap/Device	____________________
	Chemigation or Drip	(other than soil)
	Coating (i.e. Seed)	Paint or Coating	Turf Treatment or Drench

3.Type of Formulation - Check the one box which best describes the product formulation.

	Solids
	Dust/Powder	Impregnated Material	Pressurized Dust	Dry Flowable
	Granular/Flake	Microencapsulated	Soluble Powder	Other, Dry
		Pellet, Tablet, Cake	Wettable Powder
		or Briquet
	Liquids			Other
	Aqueous (Liquid)	Gel, Paste, Cream	Pressurized Liquid/	Other (specify):
	Concentrate	Oil	Sprays/Foggers
				____________________
	Emulsifiable	Paint or Coatings	Solution/liquid
	Concentrate		(ready-to-use)
		Pressurized Gas
	Flowable Concentrate		Suspension
			Other Liquid

4.Use of Pesticide - Check all that apply:

Agricultural	Household/Home Garden	Institutional -	Industrial End Use
		hospitals, schools, etc.
Structural	Manufacturing/Reformulation Only		Other:
5. Label Signal Word
Danger	Warning	Caution	None
Poison/Danger

		Product Formulation Information
	1.	Brand Name: __________________________________________ 3. U.S. EPA/Calif. Reg. No. (if assigned) :_________________________
DPR FORM 39-030 (Rev. 05/06)	2.	Firm Name: _____________________________________________________________________ 4. pH (if water soluble liquid) ___________
Page 3 of 6

INCOMPLETE FORMS WILL NOT BE PROCESSED.

If any section does not apply to your product, please mark it N/A. A separate application form must be completed for each product, each product brand name, each alternate formula and each revised formula. If you need further assistance to complete this form, contact the Pesticide Registration Branch at (916) 445-4400.

PRODUCT INFORMATION

1.Firm Name: This must be the same as on file with U.S. EPA.

2.Firm Mailing Address: Correspondence, licenses, notices, etc. will be sent to this address.

4.Name of Authorized Representative: The person who is authorized to answer any questions about your application for registration. Generally, this is the person who prepares the application. If the person is an agent, a letter from the firm authorizing

the agent to act on their behalf is required.

7.E-mail address: In accordance with California Notice to Registrants 2005-4, supplying DPR with this information will automatically enroll the applicant (firm or agent) into the automatic notification program. Applicants that do not wish to receive these automatic email updates must specify this in their cover letter or on the application form.

8.Product Brand Name: This must be EXACTLY the same as the brand name registered (or, if applicable, received) by U.S. EPA and the same as on the product labeling. The product brand name cannot be the same as another product, within the same company, with a different formulation. Do not include symbols used in place of words that are part of the brand name (e.g. @, TM, *, (R), etc.).

9.U.S. EPA Registration Number: Required unless the product is exempt from, or does not require, registration under the Federal Insecticide Fungicide and Rodenticide Act (FIFRA) such as spray adjuvants or section 25(b) exempt pesticides, or the product is

being submitted concurrent with submission to U.S. EPA under the Department’s current policy.

11.Type of California Registration Action Requested:

*New Product: Product is not yet registered in California.

*Additional Brand Name: For a product already registered in California.

*Change of Company Ownership: Applications submitted to register products under the new company ownership.

*Change of Company Name Only: There is no change in ownership.

*Alternate Formula: Another U.S. EPA accepted formulation for a currently registered product.

*Revised Formula: Replacing the existing formula on file for a currently registered product.

*Interim Registration: Under certain circumstances (FAC §13161), provides deferral of certain groundwater and efficacy data.

*Section 24c (Full Product): This is a section 24c which is not using a product registered in California. Needs license issued.

*Other: Please attach a cover letter explaining the type of registration action requested.

13.Container Type(s), Composition(s) and Size(s): Describe the actual container(s) which hold the formulated product.

For example: 16oz. plastic bottle, 1, 2 and 5 gallon plastic buckets, 55 gallon steel drum.

14.Density: Liquid Products: The pound weight of one gallon of the formulated product.

Solid Products: Total weight per cubic foot of the formulated product.

If your product is registered, a Certificate of Registration (license) will be issued to you, authorizing sales for the remainder of the calendar year. Pesticide products may not be offered for sale until a Certificate of Registration has been issued.

If revised labeling is accepted for a registered product, the applicant will receive a letter of acceptance and a copy of the product labeling stamped "Labeling Acceptable". The Department of Pesticide Regulation, Pesticide Registration Branch, must accept all labeling to be used in connection with the sale of a product prior to sale or use of the product.

Renewal of Registration:

In October of each year, you will be sent an Application for Renewal of Pesticide Registration, listing all currently registered products. To apply for renewal of these products, registrants must sign and return the form with the appropriate fee ($750 per product). A penalty is assessed on all renewal requests received after January 31. Licenses will be renewed when the fees are processed by DPR and are not retroactive to January 1.

EXTRACTS:

Copies of extracts from the Food and Agricultural Code and the California Code of Regulations dealing with pesticide registration may be obtained by writing to:

Department of Pesticide Regulation

Pesticide Registration Branch

P.O. Box 4015

Sacramento, California 95812-4015

Information Available on the Internet

Information about the California laws and regulations governing pesticide registration, as well as Department notices, policies and procedures is available on the Internet at <http://www.cdpr.ca.gov>. Information on currently registered products, registrants, telephone numbers for Department staff, and other information is also available at this site.

Persons interested in receiving notices specific to registration issues must subscribe to the e-mail list or access the “California Notices to Registrants” web page found on the Departments’ website.

To subscribe to “California Notices to Registrants” for e-mail delivery, visit the E-List page at <http://www.cdpr.ca.gov/docs/listserv/listdesc.htm>, and click on the subscribe link under the list name. An alternate method of subscribing is to send an e-mail to canote-request@pestreg.cdpr.ca.gov and put the word “subscribe” in the subject line. You will receive an e-mail, welcoming you to the list. To access new and historical notices via the Internet, see <http://www.cdpr.ca.gov/docs/canot/camenu.htm>.