Dpr Form 39 030 PDF Details

When filling out the Dpr Form 39 030, also known as the Live Water Use Report, there are several items you will need to have on hand. This form is used to report all water withdrawals from public water systems in California. The form must be filed by the owner or operator of a public water system each year. Below we provide a list of what you will need to complete the form, as well as instructions on how to submit it.

QuestionAnswer
Form NameDpr Form 39 030
Form Length6 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 30 sec
Other namesapp_pest_regist california dpr 035 form

Form Preview Example

DPR FORM 39-030 (Rev. 05/06) Page 1 of 6

APPLICATION FOR

PESTICIDE

REGISTRATION

DPR USE ONLY:

Tr. ID# ________________________________________

Reg. No._______________________________________

R.S. Assigned __________________________________

New CA Registrant

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

Mail completed application to:

For correspondence only: Department of Pesticide Regulation Pesticide Registration Branch P.O. Box 4015

Sacramento, California 95812-4015

For package deliveries, Fed Ex, etc: Department of Pesticide Regulation Pesticide Registration Branch

1001 I Street

Sacramento, California 95814-2828

DPR USE ONLY:

RC# _______________________________

_______________________________

Fee$ ______________________________

_______________________________

RC Date ___________________________

_______________________________

Date Received ______________________

_______________________________

OK by _____________________________

Date Licensed____________________

Returned __________________________

________________________________

DPR FORM 39-030 (Rev. 05/06) Page 2 of 6

Brand Name, EPA Reg. No.

Product Characterization Information

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:

Adjuvant (inc. water

Defoliant

Herbicide

modifiers)

 

Desiccant

Insect Growth

 

 

Algaecide

 

Disinfectant/Sanitizer

Regulator

 

 

 

 

Anti-foulant

 

Fertilizer

Insecticide

 

 

 

 

Antimicrobial

 

Fungicide

Miticide/Acaricide

 

 

 

 

Avicide

 

Plant Growth

Molluscicide

 

 

 

 

Bactericide/

 

Regulator

Nematicide

Bacteriostat

 

 

 

 

This pesticide a

Microbial (product itself is composed of microbes)

Biochemical

Pheromone

Repellent

Slimicide

Vertebrate Control

Virucide

Other (specify):

____________________

Chemical

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

 

 

5. Active Ingredient

Give common chemical name for each active ingredient listed on the label. Microbials should show genus, species, and strain.

6.Chemical Abstracts Service (CAS) (or ATCC) No.

7.Brand name of source product for active ingredient

8.EPA Reg. No. of source product

9.Percent by

weight of source product in formulated product.

10.Percent by weight of active ingredient in formulated product.

11. Inert Ingredient (common chemical name)

12.Chemical Abstracts Service (CAS) No.

13.Brand name of source product for inert ingredient.

14.Purpose in

formulation.

15.Percent by weight of source product in formulated product.

16.Percent by weight of inert ingredient in formulated product.

If space is not sufficient, attach additional pages. Inert ingredients information given on this form is considered to be confidential business information and is protected from disclosure under the California Public Records Act (Gov. Code §6254.2(l)). You may submit a copy of your USEPA Confidential Statement of Formula in lieu of this page.

Total _________

Columns 9 + 15 =100.00%

Total __________

Columns 10+16 =100.00%

DPR FORM 39-030 (Rev. 05/06) Page 4 of 6

Instructions for

APPLICATION FOR

PESTICIDE

REGISTRATION

DEPARTMENT OF PESTICIDE REGULATION PESTICIDE REGISTRATION BRANCH (916) 445-4400

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.

An Application Package must include the following:

A cover letter describing the type of registration action requested and what is being submitted to DPR.

A completed application form (pages 1 through 3.) Make sure your application form is complete and signed. Keep a photocopy for your records.

An application fee of $750.00 is required for new products, additional brand names, and company ownership changes. Make check or money order payable to “Department of Pesticide Regulation”.

Six (6) copies of the product labeling. Typescript labeling may be submitted if printed labels are not yet available; printer's proofs or final printed labels are required prior to issuance of a Certificate of Registration.

Copy of U.S. EPA - stamped accepted label, and U.S.EPA Notice of Registration, if applicable.

One copy of the data required by California regulations (Title 3 CCR §6170).

If not submitting data, include in your cover letter a reference to specific data on file with DPR or identification of a pesticide product(s) previously approved by the Director that would be subject to some or all of the same data requirements as applicable to the applicant’s product. NOTE: Applicant’s that rely upon data owned by another company may, pursuant to FAC §12811.5, have certain obligations to the data owner in specifically defined situations. For further information, please refer to <http://www.cdpr.ca.gov/docs/legbills/ab1011/ resource.htm>.

Interim registration applications (FAC §13161), require an additional $5,000 fee.

DPR FORM 39-030 (Rev. 05/06)

Page 5 of 6

Certificate of Registration/ Acceptance

Additional Registration Information

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>.

___________________________________________________________________________________________________________________________

APPLICATION FOR PESTICIDE REGISTRATION - PRODUCT FORMULATION INFORMATION

You can submit either page three of the California application Form 39-030 or a copy of your U.S.EPA Confidential Statement of Formula Form. Applications with incomplete product formulation information cannot be processed, and the first page will be returned.

5.Active Ingredient: List each active ingredient in this formulation as it appears on the label. Please list all active ingredients from one source product together for ease of calculation of percentages.

6.CAS No.: The CAS Number may be obtained from the Chemical Abstract Service of the American Chemical Society, P.O. Box 3012, Columbus, Ohio, 43210. Microorganisms should be identified by ATCC (American Type Culture Collection) or other recognized type culture collection number.

7.Name of Source Product: The name of the product which provides that active ingredient in the formulation.

9.Percent By Weight of Source Product in Formulated Product: Each source product listed in Column #7 must have a value in Column #9. For example, if active ingredient A and active ingredient B are both from the same source product which makes up 50% of the formulated product, the single entry in Column 9 is 50%.

10.Percent By Weight of Active Ingredient in Formulated Product: This percentage should be identical to that given on the labeling.

11.Inert Ingredient: List each inert ingredient component in this formulation. NOTE: If you do not know the identity of an inert ingredient in your product, have your supplier submit the chemical name of each inert ingredient, source product name, purpose in formulated product and percent by weight of the source product in the

formulated product directly to this office, with reference to your firm name, your product brand name and EPA Reg. No.

13.Brand Name of Source Product: The name of the product which is the source of the inert ingredient listed in Column #11.

15.Percent by Weight of Source Product in Formulated Product: Give the percentage by weight of each SOURCE PRODUCT in the formulated product. If the percent of a source product is already listed in column #9, do not list the same figure again in column #15.

16.Percent by Weight of Inert Ingredient in the Formulated Product: The percentage by weight of the inert ingredient in column #11 in the formulated product.

5. Active Ingredient

6. Chemical

7. Brand name of source

8. EPA Reg. No. of

9. Percent by

10. Percent by

Give common chemical name for each active ingredient listed

Abstracts

product for active ingredient

source product

weight of source

weight of active

on the label. Microbials should show genus, species, and

Service (CAS)

 

 

product in the

ingredient in

strain.

(or ATCC) No.

 

 

formulated

formulated product.

 

 

 

 

product.

 

pyrethrins

121-21-1

Pyrotech Concentrate

123-123

50.000%

0.010%

piperonyl butoxide

51-03-6

 

 

 

0.005%

11. Inert Ingredient (common chemical name)

12. Chemical

13. Brand name of source

14. Purpose in

15. Percent by

16. Percent by

 

Abstracts

product for inert ingredient.

formulation.

weight of source

weight of inert

 

Service (CAS)

 

 

product in the

ingredient in the

 

No.

 

 

formulated

formulated product.

 

 

 

 

product.

 

inerts from PyroTech Concentrate

-

Pyrotech Concentrate

inerts from technical

-

49.985 %

petroleum distillate

8002-05-9

SoluSolv

diluent

50.000%

50.000%

 

 

 

 

TOTAL Columns

TOTAL Columns

 

 

 

 

9 + 15 =100.00%

10+16=100.00%

U.S.EPA Confidential Statement of Formula Form: If you submit a copy of the U.S. EPA Confidential Statement of Formula, you should ensure that source products are adequately identified. Sources of active ingredient must be identified by U.S. EPA registration number. If an active ingredient source product is not separately registered in California, information concerning the composition of this product will be required.

DPR FORM 39-030 (REV 05/06)

PAGE 6 of 6

How to Edit Dpr Form 39 030 Online for Free

Working with PDF documents online is certainly easy with our PDF tool. Anyone can fill in Dpr Form 39 030 here and try out various other functions available. To keep our tool on the forefront of convenience, we aim to adopt user-driven capabilities and enhancements regularly. We're routinely grateful for any feedback - join us in remolding how we work with PDF docs. All it requires is several simple steps:

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This document will need particular data to be typed in, hence you need to take the time to type in what's asked:

1. When submitting the Dpr Form 39 030, ensure to complete all of the essential blanks in their associated form section. This will help speed up the work, making it possible for your details to be processed without delay and accurately.

Filling out section 1 in Dpr Form 39 030

2. Immediately after the previous section is completed, go to type in the suitable information in all these - cid New Product cid Additional, Density, Liquid Product Lbs per Gallon, Solid Product Lbs per Cubic Foot, I certify under penalty of perjury, Signature of Authorized, Type or Print NameTitle, Date Signed, Mail completed application to For, DPR USE ONLY, and RC Fee RC Date Date Received.

Solid Product  Lbs per Cubic Foot, cid New Product cid Additional, and DPR USE ONLY inside Dpr Form 39 030

Be really mindful while filling in Solid Product Lbs per Cubic Foot and cid New Product cid Additional, because this is the section where most people make mistakes.

3. Within this stage, have a look at DPR FORM Rev Page of, Product Characterization, Brand Name EPA Reg No, Type of pesticide Check one or, cid Adjuvant inc water, cid Defoliant, modifiers, cid Algaecide, cid Antifoulant, cid Antimicrobial, cid Avicide, cid Bactericide Bacteriostat, cid Desiccant, cid DisinfectantSanitizer, and cid Fertilizer. All these should be filled in with greatest precision.

Dpr Form 39 030 writing process shown (portion 3)

4. This specific paragraph arrives with the next few fields to look at: cid Attached eg collar, cid Filtration System, eartag, cid Bait, cid Broadcast, cid Fog, cid Fumigation, cid Injection, cid Chemigation or Drip, other than soil, cid Coating ie Seed, cid Paint or Coating, chisel or work into soil, cid Water Application, and cid Spray.

Dpr Form 39 030 writing process described (stage 4)

5. While you get close to the completion of your document, there are several more requirements that must be satisfied. Mainly, Use of Pesticide Check all that, cid HouseholdHome Garden cid, cid Industrial End Use, hospitals schools etc, cid Structural, cid ManufacturingReformulation Only, cid Other, Label Signal Word, cid Danger, cid PoisonDanger, cid Warning, cid Caution, and cid None must all be done.

Dpr Form 39 030 conclusion process described (stage 5)

Step 3: As soon as you have reviewed the details in the document, click "Done" to conclude your form. Sign up with us right now and immediately obtain Dpr Form 39 030, all set for downloading. All alterations you make are kept , allowing you to change the pdf later on as required. FormsPal guarantees your data privacy with a protected system that never records or shares any kind of personal data involved in the process. Be confident knowing your documents are kept safe each time you use our tools!