U.S. EPA RESTRICTED USE PESTICIDE
Application Record Keeping and Training Requirements Form
Applicator
s must keep the following records for a period of two years; records must be generated within 14 days of
application and a record must be kept for every individual application. Records must be made available to
State Pesticide Control Official(s), USDA, and EPA upon request. The following information must be recorded
and kept as required by the Federal Pesticide Record Keeping Program, 7 CFR Part 110:
Full Name of Certified Applicator
State Certification #
Product Name
EPA Reg #
Date of Application
Crop Location of the Application
How was the product applied? Preemergence Postemergence If post, how many days after planting?
Spray Nozzle Type Spray Pressure
(List all pesticides, adjuvants, and other products - EPA Reg # only required for pesticides)
Product EPA Reg # Product
EPA Reg #
Rate (fl ozs/A) Acres Treated
Total Amount Applied (fl ozs/A)
=
Start Time End Time
Air Temperature
º F
Air Temperature
º F
(at boom height) (at boom height)
Wind Speed
mph
Wind Speed
mph
(at boom height) (at boom height)
Wind Direction Wind Direction
Date
Method of cleanout
1
At a minimum, records must include the date the applicator consulted the specialty crop registry or surveyed neighboring fields, and the name of the specialty crop registry the applicator consulted.
2
Prior to applying this product, all applicators must complete dicamba or auxin-specific training. If training is available and required by the state where the applicator intends to apply this product, the
applicator must complete that training before applying this product in-crop. If your state does not require auxin or dicamba-specific training, then the applicator must complete dicamba or auxin-specific
training provided by one of the following sources: a) a registrant of a dicamba product approved for in-crop use with dicamba-tolerant crops, or b) a state or state-authorized provider.
Pre-ApplicationApplication Tank Mixes Spraying Conditions Cleanout
I have purchase receipts (check for yes)
I have a copy of the product label and any state special local needs labels
(check for yes)
Name and date of sensitive crop registry consultation
Registry
-OR -
Date neighboring fields were surveyed for susceptible crops
1
Date of dicamba or auxin-specific training completion
2
Provider
Applicator Name
(if different from Certified Applicator)
Before Application
After Application
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