Form DPR-032 "Structural Pest Control Device Registration Application" - California

What Is Form DPR-032?

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

Form Details:

  • Released on October 1, 2012;
  • The latest edition provided by the California Department of Pesticide Regulation;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DPR-032 by clicking the link below or browse more documents and templates provided by the California Department of Pesticide Regulation.

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Download Form DPR-032 "Structural Pest Control Device Registration Application" - California

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State of California
Department of Pesticide Regulation
Pesticide Registration Branch
Environmental Protection Agency
P.O. Box 4015
STRUCTURAL PEST CONTROL DEVICE
Sacramento, California 95812-4015
REGISTRATION APPLICATION
(916) 445-4400
DPR-032 (Rev. 10/12)
FAX (916) 324-5872
Page 1 of 4
Web site: www.cdpr.ca.gov/docs/registration/regmenu.htm
1. Firm Name
2. Mailing Address of Applicant
City
State
Zip Code
3. Street Address (If different from above)
City
State
Zip Code
4. Name of Authorized Representative
5. Telephone Number of Authorized Representative
6. FAX Number
7. E-mail Address
(
)
(
)
8. Device Brand Name (exactly as shown on the device label)
9. U.S. EPA Establishment Number
10.
List any current federal and/or state approvals for the device:
Federal Food and Drug Administrations'
Dept. of Health and Human Services Number:
_________________________________
Federal Communications Commission Number
_________________________________
California Dept. of Public Health Number:
_________________________________
Other:
_________________________________
_________________________________
_________________________________
11.
Type of Device:
12.
Wood destroying insects intended to be prevented, eliminated,
destroyed, repelled, attracted, or mitigated by the device
:
Heat
Electrical
Drywood Termites
Other: __________________
__________________
Microwave
Subterranean Termites
__________________
__________________
Other:
Carpenter Ants
__________________
Powder Post Beetles
For DPR Registration Branch Use Only
For DPR Administrative Services Use Only
Tracking Identification Number: ___________________
Registration Number: ___________________________
Approved By:__________________________________
Date Licensed:_________________________________
Date returned, if applicable:_______________________
13. I certify, under penalty of perjury, that all information submitted on this application for registration is accurate and
complete.
Signature of Authorized Representative
Type or Print Name/Title
Date Signed
X
State of California
Department of Pesticide Regulation
Pesticide Registration Branch
Environmental Protection Agency
P.O. Box 4015
STRUCTURAL PEST CONTROL DEVICE
Sacramento, California 95812-4015
REGISTRATION APPLICATION
(916) 445-4400
DPR-032 (Rev. 10/12)
FAX (916) 324-5872
Page 1 of 4
Web site: www.cdpr.ca.gov/docs/registration/regmenu.htm
1. Firm Name
2. Mailing Address of Applicant
City
State
Zip Code
3. Street Address (If different from above)
City
State
Zip Code
4. Name of Authorized Representative
5. Telephone Number of Authorized Representative
6. FAX Number
7. E-mail Address
(
)
(
)
8. Device Brand Name (exactly as shown on the device label)
9. U.S. EPA Establishment Number
10.
List any current federal and/or state approvals for the device:
Federal Food and Drug Administrations'
Dept. of Health and Human Services Number:
_________________________________
Federal Communications Commission Number
_________________________________
California Dept. of Public Health Number:
_________________________________
Other:
_________________________________
_________________________________
_________________________________
11.
Type of Device:
12.
Wood destroying insects intended to be prevented, eliminated,
destroyed, repelled, attracted, or mitigated by the device
:
Heat
Electrical
Drywood Termites
Other: __________________
__________________
Microwave
Subterranean Termites
__________________
__________________
Other:
Carpenter Ants
__________________
Powder Post Beetles
For DPR Registration Branch Use Only
For DPR Administrative Services Use Only
Tracking Identification Number: ___________________
Registration Number: ___________________________
Approved By:__________________________________
Date Licensed:_________________________________
Date returned, if applicable:_______________________
13. I certify, under penalty of perjury, that all information submitted on this application for registration is accurate and
complete.
Signature of Authorized Representative
Type or Print Name/Title
Date Signed
X
State of California
Department of Pesticide Regulation
Environmental Protection Agency
Pesticide Registration Branch
P.O. Box 4015
STRUCTURAL PEST CONTROL DEVICE
Sacramento, California 95812-4015
REGISTRATION APPLICATION
(916) 445-4400
DPR-032 (Rev. 10/12)
FAX (916) 324-5872
Page 2 of 4
Web site: www.cdpr.ca.gov/docs/registration/regmenu.htm
Application Completion Instructions
California State law [AB 1134, (Chapter 651, Statutes of 1998)] requires specific types of pest control devices
to be registered by the Department of Pesticide Regulation (DPR).
Generally, the types of devices that require registration by DPR are those that control wood destroying insects.
Those insects include, but are not limited to, termites, carpenter ants, and powder post beetles.
Devices are defined in Food and Agricultural Code (FAC) Section 15205(c)(1) as follows:
“…any method, instrument, or contrivance intended to be use to prevent, eliminate, destroy, repel,
attract, or mitigate any wood destroying pest…”
Exemption: Excluded from the definition of device are pesticides, or equipment used for the application
of pesticides, and firearms.
Wood destroying pests are defined in FAC Section 15205(c)(2) as including, but not limited to, …
"…insects such as wood borers and termites."
Exemption: Devices that claim to control wood-decaying fungi, general household pests such as
cockroaches, and vertebrate pests such as rats and mice are exempt from registration requirements.
General Application Requirements
INCOMPLETE APPLICATION FORMS WILL NOT BE PROCESSED. If any section of the application does not
apply to your product, please enter N/A for that section. If you need further assistance to complete this form,
contact DPR’s Pesticide Registration Branch at (916) 445-4400.
Application Form Completion Requirements and Instructions
The following information will help you complete this application form.
1.
Firm Name: Please insert the name of the company applying for device registration.
2.
Mailing Address: Please insert the mailing address, city, state, and zip code for the firm name
described in line 1.
3.
Street Address: Please insert the street address, city, state, and zip code for the firm listed in line 1,
if that address is different from the mailing address listed in line 2.
4.
Name of Authorized Representative: Please insert the name of an individual associated with the firm,
who should be contacted regarding device registration issues.
5.
Telephone Number of Authorized Representative: Please insert the telephone number, including
area code, for the authorized representative.
6.
FAX Number: Please insert the Facsimile number for the authorized representative. If none, please
insert “N/A.”
State of California
Department of Pesticide Regulation
Environmental Protection Agency
Pesticide Registration Branch
P.O. Box 4015
STRUCTURAL PEST CONTROL
Sacramento, California 95812-4015
DEVICE REGISTRATION
(916) 445-4400
FAX (916) 324-5872
APPLICATION
Web site: www.cdpr.ca.gov/docs/registration/regmenu.htm
DPR-032 (Rev. 10/12)
Page 3 of 4
Application Form Completion Requirements and Instructions (continued)
7.
E-mail Address: Please insert the e-mail address for the authorized representative. Example:
Jjones@companyname.com. If none, please insert "N/A.”
8.
Device Brand Name: Please insert the brand name for the device. Example: “Bugkiller.”
9.
U.S. EPA Establishment Number: Under federal laws and regulations, anyone who "produces" pest
control devices, as defined, must obtain an Establishment Number for each producing location from the
United States Environmental Protection Agency (U.S. EPA). Under federal laws and regulations,
a "device" is any instrument or contrivance (other than a firearm) intended for trapping, destroying,
repelling, or mitigating any pest. U.S. EPA does not require devices to be registered with the Agency,
however, devices are subject to certain federal labeling, packaging, record keeping, and
import/export requirements.
Please enter the U.S. EPA Establishment Number for the device on line 9. For further information
concerning federal pest control device establishment requirements, please contact U.S. EPA
Region IX, Office of Pesticide Programs, 75 Hawthorne Street, San Francisco, California 94105,
(415) 744-1066.
10.
Federal/State Device Approvals: Please indicate current federal/state approvals for the device.
11.
Type of Device: Please indicate the type of device for which the application is submitted.
12.
Wood Destroying Pest(s): Please indicate the type of pests intended to be prevented, eliminated,
destroyed, repelled, attracted, or mitigated by the device.
13.
Signature/Date: The authorized representative must sign the application form, and include the date of
the signature.
The device application package must contain the following items:
A. Cover Letter: A cover letter describing the type of registration action requested, and describing what
information is being submitted to DPR.
B. Application Form: The completed Structural Pest Control Device Registration Application (form DPR-032).
Ensure that the application form is complete and signed. It is suggested that a photocopy of the application
materials be maintained for your files.
C. Application Fee: An application fee of $200.00 is required to be submitted with each application to register
a structural pest control device. Make check or money order payable to the Cashier, Department of
Pesticide Regulation. No currency or coin will be accepted.
D. Labeling: Six (6) copies of the device product labeling. The labeling must include:
Printed directions for use of the device.
The name, brand, or trademark under which the device will be sold.
The name and address of the device manufacturer, importer, dealer, or vendor.
Any necessary safety precautionary statements associated with the use of the device.
State of California
Department of Pesticide Regulation
Environmental Protection Agency
Pesticide Registration Branch
P.O. Box 4015
STRUCTURAL PEST CONTROL
Sacramento, California 95812-4015
DEVICE REGISTRATION
(916) 445-4400
FAX (916) 324-5872
APPLICATION
Web site: www.cdpr.ca.gov/docs/registration/regmenu.htm
DPR-032 (Rev. 10/12)
Page 4 of 4
Application Form Completion Requirements and Instructions (continued)
E. Device Principles of Operation: Please describe the specific principles (electrical, thermal, microwave,
acoustic, etc.) of how the device operates.
F. Device Efficacy Data: Please provide data/studies that support the efficacy of the device as claimed on the
device label and device promotional materials.
G. Device Human and Animal Safety Data: Please identify any hazard(s) to applicators, bystanders, and
animals associated with use of the device. Please include any information/data/studies supporting how the
identified safety hazards are mitigated.
H. Device Structural Integrity (Property Safety) Data: Please provide a certification from a California State
licensed professional engineer (P.E.) with documented structural engineering expertise, that use of the
device will not weaken the structural integrity or cause damage to the structure of the property being
treated. Submit to DPR all information/data provided to the structural engineer to assist with making
his/her determination.
NOTE: All data submissions (items F, G, and H) must follow format guidelines specified in DPR's
California Notice
2006-06, dated August 10, 2006.
Mailing and Payment Instructions
Mail the completed application, supporting information, and application fee to:
For standard mail:
For package deliveries, Fed Ex, etc:
Department of Pesticide Regulation
Department of Pesticide Regulation
Pesticide Registration Branch
Pesticide Registration Branch
P.O. Box 4015
1001 I Street
Sacramento, California 95812-4015
Sacramento, California 95814-2828
Certificate of Registration
If your device is registered by DPR, a Certificate of Registration (license) will be issued to you, authorizing sale
and use of the device in California. Device products may not be offered for sale or used in California until a
Certificate of Registration has been issued by DPR.
All labeling, including changes to labeling, used in connection with the sale of a device must be accepted by
DPR’s Pesticide Registration Branch, prior to sale or use of the device.
Law Extracts
The text of all California Codes (laws) is available on an Internet web site maintained by the State of California,
www.leginfo.ca.gov/calaw.html
Office of the Legislative Counsel:
. Provisions of the Food and Agricultural
Code and the Business and Professions Code pertaining to the structural pest control device registration
program are currently contained in Food and Agricultural Code Sections 12996, 12998, 12999, 12999.2,
12999.4, 12999.5, 15205, and 15300 - 15340; and in Business and Professions Code Sections 8646, and
8674.5. Extracts from the codes pertaining to the Structural Pest Control Device Registration Program are also
available from DPR upon request.
Page of 4