1. EPA REG. NO.
-
-
Office Use Only
EPA Dates
Payor
Restricted Code(s)
Density (lbs/gal):
PRODUCT INFORMATION FORM - Please see instructions on the next page
3. If Applicable:
Biopesticide
Reduced Risk (Attach reduced risk confirmation letter)
Groundwater Adv.
4. ACTIVE INGREDIENTS (As shown on product label)
2.
1.
3.
4.
2. Product Name
Percentage
No aerial in NY
No use on L.I.
New York State Department of Environmental Conservation
Pesticide Product Registration Section
625 Broadway, Albany, NY 12233-7257
SRD
%
%
%
%
Surface Water Adv.
ABN
Piscicide
Nematicide
Molluscide
Miticide
Insecticide
Herbicide
Growth Regul
Fungicide
Disinfectant
Defoliant
Avicide
Antifoulant
Antimicrobial
Algaecide
TYPE
Rodenticide
Wood Preserv
Termiticide
Repellent
Liquid
Solid
None
Danger
Caution
SIGNAL WORD
Warning
ROUTE OF
EXPOSURE
Inhalation
Dermal
Oral
None
Domestic Animals
Wildlife
Bees
Birds
Fish
Aquatic Inv.
TOXICITY
Institutional
Industrial
Household
Hospital
Home Garden
Seed Treatment
Dom Animal
Aquatic
USE
Commercial
Agricultural
Structural
Turf
Swim. Pool/Spa
Residential
Personal
Ornamental
Nursery
Non-Crop
Manufacturing
Larvicide
Office Use Only
FORMULATION
%
5.
Limited aerial in NY
Partial use on L.I.
Eyes
Sanitizer
Greenhouse
LABEL CONDITIONS
No app w/100ft of water
No app to water
Limited app to wetland
No app to wetland
None
Paper
Disc
L:
CSF
Livestock
Adulticide
Plant Inc. Prot.
4. Enter the active ingredients and percentages as shown on the final product label.
3. If applicable, indicate whether the product is a biopesticide or was classified as reduced risk by the EPA. If reduced risk, please attach EPA confirmation letter.
2. Enter the product name in the field provided.
1. Enter the product EPA Registration Number in the appropriate boxes. The third box will only be used for supplemental distributor products.
Complete a separate Product Information Form for each product listed on the application form. This is a fillable form. All necessary fields may be filled using Adobe
Acrobat and then printed. The form may also be printed or copied and filled by hand. The information requested on this form should be taken directly from the final
product label. Please refer to the Pesticide Product Registration Section's webpage at http://www.dec.ny.gov/chemical/8528.html for further information regarding
pesticide product application procedures in New York. PLEASE DO NOT MAKE ANY MARKS IN THE OFFICE USE ONLY BOXES. Please call
(518) 402-8768 or email ppr@dec.ny.gov with questions.
PRODUCT INFORMATION FORM INSTRUCTIONS