Groundwater Protection Program Notification Form

You must notify the Department of Agricultural Resources Pesticide Bureau when you apply a pesticide product which is listed on the groundwater protection list. Notifications must be made to the Department within ten days of the end of the calendar month of use. This form can be used for multiple applications. Thank you for your assistance!

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Fields in red are required.

FIRST NAME: LAST NAME:

PESTICIDE LICENSE NUMBER:

DAYTIME PHONE: (include area code)

E-MAIL ADDRESS:

ADDRESS:

CITY: STATE: ZIP:

LOCATION(S) AND DATE(S) OF PESTICIDE APPLICATION:

PRIMARY RECHARGE AREA (Zone II or IWPA and town)

PESTICIDE USED INCLUDING EPA REGISTRATION NUMBER

PURPOSE OF APPLICATION

ADDITIONAL COMMENTS: