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. Please submit one form per site. Thank you for your assistance!

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 AND DATE(S) OF PESTICIDE APPLICATION:

PRIMARY RECHARGE AREA (Zone II or IWPA and town)

PESTICIDE(S) USED INCLUDING EPA REGISTRATION NUMBER

PURPOSE OF APPLICATION

ADDITIONAL COMMENTS:

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