Form PR-REG-003 "Application for Section 18 Emergency Exemption" - California

What Is Form PR-REG-003?

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 March 1, 2010;
  • 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;

Download a printable version of Form PR-REG-003 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 PR-REG-003 "Application for Section 18 Emergency Exemption" - California

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State of California
Department of Pesticide Regulation
Pesticide Registration Branch
PR-REG-003 (Est. 7/91) (Rev. 3/10)
APPLICATION
FOR SECTION 18 EMERGENCY
EXEMPTION
The following information is required for an emergency exemption request based on the revised United States Environmental Protection Agency
(USEPA) Code of Federal Regulations, Title 40, Part 166 concerning Section 18 requests. Requests which are incomplete will be denied by the
USEPA without review. In order to comply with these requirements, the information listed below must be provided. Use additional pages if
necessary. Please note that the more complete the questionnaire, the better your chances are of obtaining the exemption.
[ ] Check box if this is a reissuance request. (Year
)
TYPE OF EXEMPTION BEING REQUESTED (check one)
[ ] SPECIFIC
[ ] QUARANTINE
[ ] PUBLIC HEALTH
DESCRIPTION OF PESTICIDE REQUESTED
Common Chemical Name
_____________________________________________________
(Active Ingredient):
Trade Name/Brand Name: ____________________________________________
U.S. EPA Reg. No.: ____________________________________________________
Formulation:
% Active Ingredient: _______________%
Manufacturer: _______________________________________________________
1
State of California
Department of Pesticide Regulation
Pesticide Registration Branch
PR-REG-003 (Est. 7/91) (Rev. 3/10)
APPLICATION
FOR SECTION 18 EMERGENCY
EXEMPTION
The following information is required for an emergency exemption request based on the revised United States Environmental Protection Agency
(USEPA) Code of Federal Regulations, Title 40, Part 166 concerning Section 18 requests. Requests which are incomplete will be denied by the
USEPA without review. In order to comply with these requirements, the information listed below must be provided. Use additional pages if
necessary. Please note that the more complete the questionnaire, the better your chances are of obtaining the exemption.
[ ] Check box if this is a reissuance request. (Year
)
TYPE OF EXEMPTION BEING REQUESTED (check one)
[ ] SPECIFIC
[ ] QUARANTINE
[ ] PUBLIC HEALTH
DESCRIPTION OF PESTICIDE REQUESTED
Common Chemical Name
_____________________________________________________
(Active Ingredient):
Trade Name/Brand Name: ____________________________________________
U.S. EPA Reg. No.: ____________________________________________________
Formulation:
% Active Ingredient: _______________%
Manufacturer: _______________________________________________________
1
CONTACT PERSON(S) AND QUALIFIED EXPERT(S)
APPLICANT:
Signature: _______________________________
Name:
Title:
Date: _______________________________
Organization: _________________________________
Address: _____________________________________
_____________________________________
FAX # _________________
Telephone:
E-Mail: __________________________________________
QUALIFIED EXPERT(S)
Name: _________________________________
Name:
Title: __________________________________
Title:
Organization:
Organization: ___________________________
Address:
Address: ________________________________
________________________________
Telephone:
Telephone: _____________________________
Name:
Name__________________________________
Title:
Title: _________________________________
Organization:
Organization: __________________________
2
Address: _______________________________
Address:
_______________________________
Telephone:
Telephone: _____________________________
DESCRIPTION OF PROPOSED USE
Sites to be Treated: (i.e. crops, structures, etc.)
Statewide or County Specific (list counties):
Method of Application:
Rate of Application (in terms of a.i. and product):
(Include dilution rate)
Frequency/Timing of Application:
Maximum Number of Applications:
Total Acreage (or other units) Planted and to be Treated:
Total Amount of Pesticide to be used (in terms of a.i. and product):
Use Season (period of time for which use of chemical is requested):
Date First Application Needed:
Date Last Application Needed:
Restricted Entry Interval (REI):
Preharvest Interval (PHI):
Earliest Harvest Date:
Additional Restrictions, User Precautions and Requirements, Qualifications of Applicators, etc.:
3
EXPECTED RESIDUE LEVELS IN FOOD
(Residue data included as separate attachment)
ALTERNATIVE METHODS OF CONTROL
(Efficacy data and/or other information included as a separate attachment)
Registered Alternative Pesticides:
Alternative Control Practices:
EFFICACY OF USE PROPOSED UNDER SECTION 18
(Efficacy data and/or other information included as a separate attachment)
(Efficacy data should include statistical data on comparative California registered products. This data should
also compare the California registered products to the proposed product. Effects on crop yield
and quality should also be documented.)
COORDINATION WITH OTHER AFFECTED FEDERAL,
STATE, and LOCAL AGENCIES
The appropriate state agencies are also being notified of this specific exemption request through routine weekly
notices which the Department of Pesticide Regulation distributes. Comments received after the submission of
this request will be forwarded to the United States Environmental Protection Agency (USEPA).
NOTIFICATION OF REGISTRANT
A Letter of Authorization from the Registrant and copy of product label (included as separate attachment).
4
REPEAT USES
(Interim Use Report)
The interim use report must address the following:
1.
Amount of product used
2.
Acreage treated
3.
Number of permits issued
4.
Estimate of effectiveness
5.
Any adverse effects - Includes subjects such as: worker injuries, water contamination, effects
on fish, wildlife, honeybees, and domestic animals and damage to nontarget
plants resulting from drift.
The above information can be obtained from the Agricultural Commissioner's office from the county
or counties that used the Section 18.
PROGRESS TOWARDS REGISTRATION
(Information from registrant concerning the current status)
(Not required for Request for a Quarantine Exemption
(Check All That Apply)
[ ]
NO APPLICATION FOR REGISTRATION OF THE USE IS UNDER REVIEW BY USEPA.
[ ]
USEPA IS REVIEWING AN APPLICATION FOR REGISTRATION OF THIS USE (TYPE OF
REGISTRATION
).
[ ]
AN IR-4 PETITION FOR TOLERANCE IS BEING DEVELOPED OR IS UNDER REVIEW BY USEPA.
PETITION #
.
[ ]
A PETITION FOR TOLERANCE HAS BEEN SUBMITTED TO USEPA BY THE MANUFACTURER.
PETITION #
.
[ ]
A PETITION FOR TOLERANCE OR AN APPLICATION FOR REGISTRATION HAS BEEN DENIED
(INDICATE THE CIRCUMSTANCES
).
IF THIS USE PATTERN WILL BE NEEDED FOR MORE THAN ONE SEASON, A PERMANENT
TOLERANCE SHOULD BE PURSUED IMMEDIATELY. CONTACT THE MANUFACTURER OR IR-4
TO INITIATE THE ESTABLISHMENT OF A PERMANENT TOLERANCE.
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