Please fill out the form completely and submit two (2)copies (along
with two copies of any attachments) to the attention of: Pesticide
Registration Specialist, Department of Food and Agriculture, Pesticide
Bureau, 100 Cambridge Street, Boston, MA 02202.
PART 1: Product Information
Name and Address of Registrant Date of Application
/ /
Contact
Telephone
Product Name EPA Reg. No
Active ingredient(s) with percentages Proposed Use(s)
Proposed Application Rate Range of Application Rates on Currently
Registered EPA Label
PART 2: Efficacy
1. Summary of efficacy data (please attach reports)
2. Has any efficacy data been generated in New England? If "yes",
please list state(s):
PART 3: Environmental Fate
1. Summary of environmental fate (please attach reports)
2. Has any environmental fate been generated in New England? If
"yes", please list state(s):
PART 4: Toxicology Information
1. Acute Toxicity Information (summarize and attach
reports); include rat oral LD50 and rabbit dermal LD50 if available.
2. Chronic Toxicity Information (summarize and attach reports):
a. Oncogenic studies b. Mutagenic studies c. Reproductive studies
d. Neurotoxic studies e. Other chronic studies
3. Other (e.g., non-target organisms studies, etc):
4. Any existing health based guidelines (EPA, ADIs, FDA, WHO, etc.)
5. Exposure information, such as levels that have been found in
drinking water, foods, air, or in applicator studies.
6. Attach an updated bibliography concerning the toxicity of the
pesticide, including any review articles such as those by the FAO/WHO,
EPA, FDA, and others.
PART 5: Residues in Food or Feed (if applicable)
1. Tolerance and Federal Register citation on commodity
named in the application:
2. Residues found from actual use data: (Please list below only
those data relevant to the commodity in the application at the proposed
application rate. Any other data may be submitted as an attachment:
Application Date Date Sample Taken Residue Found (Conc.)
PART 6: Registration Status
1. Have you applied for this 24-c in any other State:
2. If "yes", please list the states and application status,
(approved, pending or denied).
State Registration Status
3. Have you applied for a Section 3 (federal) registration for this
product for use on the stated site: If "yes", date of
submission to EPA ___________________ If "no", please
briefly explain why:
___________________________________
Signature of Authorized
Representative of the Registrant
