Form 163 "License Application to Operate a Seed Treater" - Arkansas

What Is Form 163?

This is a legal form that was released by the Arkansas Agriculture Department - a government authority operating within Arkansas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2013;
  • The latest edition provided by the Arkansas Agriculture Department;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a printable version of Form 163 by clicking the link below or browse more documents and templates provided by the Arkansas Agriculture Department.

ADVERTISEMENT
ADVERTISEMENT

Download Form 163 "License Application to Operate a Seed Treater" - Arkansas

793 times
Rate (4.5 / 5) 48 votes
(501) 225-1598
FORM 163
(REV. 5/2013)
ARKANSAS STATE PLANT BOARD
LICENSE APPLICATION TO OPERATE A SEED TREATER
(License covers m ultiple treaters at plant location)
__________________________________________________________(_____)________________
NAME IN WHICH LICENSE IS TO BE ISSUED (Company)
PHONE
___________________________________________________________________________________________________________
MAILING ADDRESS
CITY
STATE
ZIP
Email address:____________________________________________________________________
STATE THE AMOUNT AND KIND OF SUBSTANCE(S) In OUNCES per Hundredweight You Intend
Using for EACH KIND OF SEED: (See Example on Attached Additional
page-provided if need more space)
Kind of Treatment
EPA
RATE
Reg.
(List Chemical to be used -each
(
KIND of SEED
List ounces per hundredweight
Num ber
Fungicide, Pesticide, etc.)
)
Or per bushel
YES
NO
____ ____
1.
DO YOU UNDERSTAND THAT YOU ARE RESPONSIBLE FOR KNOWING THE INFORMATION IN CIRCULAR
10: REGULATIONS ON THE SALE OF PLANTING SEED IN ARKANSAS, SECTIONS I & J?
_____
_____
2.
DO YOU UNDERSTAND THAT EACH TREATED BAG OF SEED MUST BEAR A POISON LABEL TRULY AND
CORRECTLY STATING THE CHEMICAL(S) WERE USED WERE IN ACCORDANCE WITH THE
MANUFACTURER’S RECOMMENDATIONS, AND IN ADDITION, THE LABEL MUST HAVE THE NAME OF THE
CHEMICAL(S) USED, AS WELL AS THE APPROPRIATE SIGNAL WORD AND PRECAUTIONARY
STATEMENT?
_____
_____
3.
DO YOU UNDERSTAND THAT IT IS ILLEGAL TO SELL, GIVE AWAY, OR USE TREATED SEED FOR ANY
PURPOSE OTHER THAN PLANTING?
_____
_____
4.
DO YOU UNDERSTAND THAT YOU MUST MAINTAIN COMPLETE RECORDS AS TO KINDS AND AMOUNTS
OF CHEMICALS USED, DATES, AND ROUTINE INVOICE INFORMATION FOR A PERIOD OF TWO YEARS
FROM THE DATE OF THE TREATMENT APPLICATION?
_____
_____
5.
DO YOU UNDERSTAND THAT THE PLANT BOARD OR ITS’ REPRESENTATIVE MAY INSPECT YOUR
RECORDS DURING NORMAL BUSINESS HOURS?
_____
_____
6.
DO YOU AGREE TO COMPLY WITH THE REGULATIONS AND THAT YOU WILL BE HELD RESPONSIBLE TO
STATE AND / OR FEDERAL PESTICIDE LAWS FOR FAILURE TO OBSERVE SAID REGULATIONS?
ANNUAL LICENSE FEE IS $250.00 FOR THE FISCAL YEAR JULY 1 - JUNE 30.
AMOUNT ENCLOSED $________________
RETURN TO:
OPERATOR IN CHARGE___________________________________________
PLEASE PRINT
ARKANSAS STATE PLANT BOARD
SEED DIVISION
SIGNATURE___________________________________________
#1 NATURAL RESOURCES DRIVE
LITTLE ROCK, AR 72205
___________________________________________
DATE
(501) 225-1598
FORM 163
(REV. 5/2013)
ARKANSAS STATE PLANT BOARD
LICENSE APPLICATION TO OPERATE A SEED TREATER
(License covers m ultiple treaters at plant location)
__________________________________________________________(_____)________________
NAME IN WHICH LICENSE IS TO BE ISSUED (Company)
PHONE
___________________________________________________________________________________________________________
MAILING ADDRESS
CITY
STATE
ZIP
Email address:____________________________________________________________________
STATE THE AMOUNT AND KIND OF SUBSTANCE(S) In OUNCES per Hundredweight You Intend
Using for EACH KIND OF SEED: (See Example on Attached Additional
page-provided if need more space)
Kind of Treatment
EPA
RATE
Reg.
(List Chemical to be used -each
(
KIND of SEED
List ounces per hundredweight
Num ber
Fungicide, Pesticide, etc.)
)
Or per bushel
YES
NO
____ ____
1.
DO YOU UNDERSTAND THAT YOU ARE RESPONSIBLE FOR KNOWING THE INFORMATION IN CIRCULAR
10: REGULATIONS ON THE SALE OF PLANTING SEED IN ARKANSAS, SECTIONS I & J?
_____
_____
2.
DO YOU UNDERSTAND THAT EACH TREATED BAG OF SEED MUST BEAR A POISON LABEL TRULY AND
CORRECTLY STATING THE CHEMICAL(S) WERE USED WERE IN ACCORDANCE WITH THE
MANUFACTURER’S RECOMMENDATIONS, AND IN ADDITION, THE LABEL MUST HAVE THE NAME OF THE
CHEMICAL(S) USED, AS WELL AS THE APPROPRIATE SIGNAL WORD AND PRECAUTIONARY
STATEMENT?
_____
_____
3.
DO YOU UNDERSTAND THAT IT IS ILLEGAL TO SELL, GIVE AWAY, OR USE TREATED SEED FOR ANY
PURPOSE OTHER THAN PLANTING?
_____
_____
4.
DO YOU UNDERSTAND THAT YOU MUST MAINTAIN COMPLETE RECORDS AS TO KINDS AND AMOUNTS
OF CHEMICALS USED, DATES, AND ROUTINE INVOICE INFORMATION FOR A PERIOD OF TWO YEARS
FROM THE DATE OF THE TREATMENT APPLICATION?
_____
_____
5.
DO YOU UNDERSTAND THAT THE PLANT BOARD OR ITS’ REPRESENTATIVE MAY INSPECT YOUR
RECORDS DURING NORMAL BUSINESS HOURS?
_____
_____
6.
DO YOU AGREE TO COMPLY WITH THE REGULATIONS AND THAT YOU WILL BE HELD RESPONSIBLE TO
STATE AND / OR FEDERAL PESTICIDE LAWS FOR FAILURE TO OBSERVE SAID REGULATIONS?
ANNUAL LICENSE FEE IS $250.00 FOR THE FISCAL YEAR JULY 1 - JUNE 30.
AMOUNT ENCLOSED $________________
RETURN TO:
OPERATOR IN CHARGE___________________________________________
PLEASE PRINT
ARKANSAS STATE PLANT BOARD
SEED DIVISION
SIGNATURE___________________________________________
#1 NATURAL RESOURCES DRIVE
LITTLE ROCK, AR 72205
___________________________________________
DATE
ATTACHMENT FOR LISTING CHEMICALS
Or attach your own form
(If extra space is needed)
EXAMPLE:
Kind of Treatment
RATE
KIND of SEED
(List Chemical to be used -
EPA Number
(List ounces per hundredweight
Each Fungicide, Pesticide, etc.)
or oz per bushel)
Apron XL LS
100-799
0.0425 fluid oz per 100wt
Maxim 4FS
100-758
0.16
RICE
Release LC
73049-42
2.1 fl oz in 20 fl oz water per 100wt
Cruiser 5FS
100-941
1.28
fluid oz per 100wt
Maxim XL
100-916
0.117
SOYBEANS
Apron XL LS
100-799
0.48
Apron MAXX RTA + Moly
100-945
5.00
Company Name & Address:__________________________________________________
Operator in Charge:_________________________________
Date:_____________
Kind of Treatment
RATE
(List Chemical to be used -each
(
KIND of SEED
EPA
List ounces per hundredweight
Fungicide, Pesticide, etc.)
)
Or per bushel
Number
*
*
The EPA registration number can be found on the label of the chemical container
Page of 2