Form DPR-REG-030 "Application for Pesticide Registration" - California

What Is Form DPR-REG-030?

This is a legal form that was released by the California Department of Pesticide Regulation - a government authority operating within California. Check the official instructions before completing and submitting the form.

Form Details:

  • Released on October 1, 2015;
  • 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-REG-030 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-REG-030 "Application for Pesticide Registration" - California

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APPLICATION FOR
State of California
DPR USE ONLY:
Department of Pesticide Regulation
PESTICIDE
Application for Pesticide Registration
Tr. ID#
DPR-REG-030 (Rev. 10/15)
REGISTRATION
Reg. No.
Page 1 of 6
RS Assigned
New CA Registrant
Applicant Information
Important: Read instructions on page 3 before completing this form
1. Firm Name
2. Mailing Address of Firm
City
State
Zip Code
Check box if new address
City
State
Zip Code
3.
Street Address (if different from above) or
Agent Address
4. Name of Authorized Representative/Agent
5. Telephone Number of Representative/Agent
6. Fax Number
7. E-mail Address
8. Product Brand Name (exactly as shown on label)
9. U.S. EPA Registration Number
10. Type of California registration action requested
11. Product Composition Statement, Attached is either
New Product
Product Formulation Information form (Page 5), or
Additional Brand Name
U.S. EPA Confidential Statement of Formula
Master Label
12. Type of U.S. EPA registration
Product Transfer
Section 3 Registration
Change of Company Ownership
Supplemental Registration of Distributor (Subregistration)
Change of Company Name Only
Section 5 Experimental Use Permit
Interim Registration (Food and Agricultural Code §13161 et seq.)
Concurrent Submission Allowed
Section 24c (Full Product)
Not Required, California-Only Registration
Other (attach cover letter)
13. Container Type(s), Composition(s), and Size(s)
14. Liquid Products Only:
Density =
lbs. per gallon,
or Specific Gravity =
Solid Products Only
lbs. per cubic foot
(Density):
I certify, under penalty of perjury, that all information submitted on this application for registration is accurate and complete. As required by
Title 3, California Code of Regulations (3 CCR) §6170, all data that we submitted to the U.S. EPA to support this product are enclosed in
this submission or have previously been submitted to DPR.
X
/
/
Signature of Authorized Representative/Agent
Type or Print Name/Title
Date Signed
DPR USE ONLY:
Mail completed application to:
For correspondence only:
RC #
Department of Pesticide Regulation
Fee $
Pesticide Registration Branch
P.O. Box 4015
RC Date
Sacramento, California 95812-4015
For package deliveries, Fed Ex, etc.:
Date Received
Department of Pesticide Regulation
OK by
Date Licensed
Pesticide Registration Branch
1001 I Street
Returned
Sacramento, California 95814-2828
APPLICATION FOR
State of California
DPR USE ONLY:
Department of Pesticide Regulation
PESTICIDE
Application for Pesticide Registration
Tr. ID#
DPR-REG-030 (Rev. 10/15)
REGISTRATION
Reg. No.
Page 1 of 6
RS Assigned
New CA Registrant
Applicant Information
Important: Read instructions on page 3 before completing this form
1. Firm Name
2. Mailing Address of Firm
City
State
Zip Code
Check box if new address
City
State
Zip Code
3.
Street Address (if different from above) or
Agent Address
4. Name of Authorized Representative/Agent
5. Telephone Number of Representative/Agent
6. Fax Number
7. E-mail Address
8. Product Brand Name (exactly as shown on label)
9. U.S. EPA Registration Number
10. Type of California registration action requested
11. Product Composition Statement, Attached is either
New Product
Product Formulation Information form (Page 5), or
Additional Brand Name
U.S. EPA Confidential Statement of Formula
Master Label
12. Type of U.S. EPA registration
Product Transfer
Section 3 Registration
Change of Company Ownership
Supplemental Registration of Distributor (Subregistration)
Change of Company Name Only
Section 5 Experimental Use Permit
Interim Registration (Food and Agricultural Code §13161 et seq.)
Concurrent Submission Allowed
Section 24c (Full Product)
Not Required, California-Only Registration
Other (attach cover letter)
13. Container Type(s), Composition(s), and Size(s)
14. Liquid Products Only:
Density =
lbs. per gallon,
or Specific Gravity =
Solid Products Only
lbs. per cubic foot
(Density):
I certify, under penalty of perjury, that all information submitted on this application for registration is accurate and complete. As required by
Title 3, California Code of Regulations (3 CCR) §6170, all data that we submitted to the U.S. EPA to support this product are enclosed in
this submission or have previously been submitted to DPR.
X
/
/
Signature of Authorized Representative/Agent
Type or Print Name/Title
Date Signed
DPR USE ONLY:
Mail completed application to:
For correspondence only:
RC #
Department of Pesticide Regulation
Fee $
Pesticide Registration Branch
P.O. Box 4015
RC Date
Sacramento, California 95812-4015
For package deliveries, Fed Ex, etc.:
Date Received
Department of Pesticide Regulation
OK by
Date Licensed
Pesticide Registration Branch
1001 I Street
Returned
Sacramento, California 95814-2828
State of California
Department of Pesticide Regulation
Application for Pesticide Registration
Product Brand Name, EPA Reg. No.
DPR-REG-030 (Rev. 10/15)
Product Characterization Information
Page 2 of 6
Information about your product and its intended uses is required to allow DPR to correctly process and prepare notices for this
application.
1. a) This pesticide is a ☐ Microbial (product itself is composed of microbes) ☐ Biochemical ☐ Chemical
b) Type of pesticide, check all boxes that apply:
Adjuvant (including.
Bactericide /
Fertilizer
Insecticide
Slimicide
water modifiers)
Bacteriostat
Fungicide
Miticide / Acaricide
Vertebrate Control
Algaecide
Defoliant
Plant Growth
Molluscicide
Virucide
Anti-foulant
Desiccant
Regulator
Nematicide
Other (specify):
Antimicrobial
Disinfectant / Sanitizer
Herbicide
Pheromone
Avicide
Insect Growth
Repellent
Regulator
2. a) Is this product applied
aerial
ground, or
both (aerial and ground)
b) Is the product soil applied?
Yes or
No
c) Application methods, check all boxes that apply:
Ant / Wasp / Rodent
Chemigation or Drip
Fumigation
Spray
Wash, Soak, Dip,
Mound
or Mop
Coating (i.e., seed)
Injection
Topically Applied
Additive
Water Application
(other than soil)
(rub on, wipe on)
Dust
Attached (e.g.,
Paint or Coating
Trap / Device
Wick Applicator
Evaporating Solid
collar, ear tag)
Smoke
Turf Treatment or
Other (specify):
Filtration System
Bait
Drench
Soil Applied (inject,
Fog
Broadcast
shank, chisel, or work
into soil)
3. Type of Formulation, check one box that best describes the product formulation:
Solids
Dust / Powder
Impregnated Material
Pellet, Tablet, Cake
Pressurized Gas
Wettable Powder
or Briquet
(Dry)
Granular / Flake
Microencapsulated
Dry Flowable
Pressurized Dust
Soluble Powder
(Dry)
Other (Dry)
Liquids
Other (specify)
Emulsifiable
Oil
Solution / Liquid
Suspension
Concentrate
(ready-to-use)
Paint or Coatings
Aqueous (Liquid)
Flowable
Pressurized Gas
Concentrate
Pressurized Liquid /
Concentrate
(Liquid)
Other (Liquid)
Sprays / Foggers
Gel, Paste, Cream
Microencapsulated
(Liquid)
4. Use of Pesticide, check all that apply:
Agricultural
Household / Home Garden
Institutional (hospitals, schools, etc.)
Industrial End Use
Structural
Manufacturing / Reformulation Only
Other: ___________________________________________
5. Label Signal Word
Poison / Danger
Danger
Warning
Caution
None
6. Does this product require child-resistant packaging?
Yes
No
7. Flash point/flame extension of products containing more than 70 percent petroleum distillates: _____________
State of California
Instructions for
Department of Pesticide Regulation
Application for Pesticide Registration
Application for Pesticide Registration
DPR REG-030 (Rev. 10/15)
Page 3 of 6
INCOMPLETE FORMS WILL NOT BE PROCESSED
If any section does not apply to your product, please mark it N/A. A separate application form must be completed for each product
and each product brand name. If you require further assistance, contact the Pesticide Registration Branch at (916) 445-4400.
Firm Name: If federally registered, this must be the same as on file with U.S. EPA.
1.
2.
Firm Mailing Address: Correspondence, licenses, notices, etc. will be sent to this address.
4.
Name of Authorized Representative: The person who is authorized to answer any questions about your application for
registration. Generally, this person prepares the application. If the person is an agent/consultant, a letter from the firm
authorizing the agent/consultant to act on its behalf is required.
8.
Product Brand Name: This must be EXACTLY the same as the brand name registered (or, if applicable, received) by U.S. EPA
and the same as on the product labeling. The product brand name cannot be the same as another product with a different
formulation. Do not include symbols used in place of words that are part of the brand name (e.g., @, TM, *, ®, etc.).
9.
U.S. EPA Registration Number: Required unless the product is exempt from, or does not require, registration under the
Federal Insecticide Fungicide and Rodenticide Act (FIFRA) such as spray adjuvants, FIFRA §25(b) exempt pesticides,
or the product is being submitted concurrent with submission to U.S. EPA under DPR’s current policy.
10. Type of California Registration Action Requested:
 New Product: A product is not yet registered in California.
 Additional Brand Name: For a product already registered in California.
 Master Label: A product label bearing most or all U.S. EPA accepted uses for that product. Master label products cannot be
sold or distributed in California.
 Product Transfer: A product sold to another registrant. The product transfer does not involve the sale or purchase of the
company itself.
 Change of Company Ownership: Applications submitted to register products under the new company ownership.
 Change of Company Name Only: There is no change in ownership.
 Interim Registration: Under certain circumstances (FAC §13161), provides deferral of certain groundwater and efficacy data.
 Section 24c (Full Product): This is a FIFRA §24c that is not using a product registered in California.
 Other: Please attach a cover letter explaining the type of registration action requested.
13. Container Type(s), Composition(s), and Size(s): Describe the actual container(s), which hold the formulated product.
For example, 16 oz. plastic bottle; 1, 2, and 5 gallon plastic buckets; 55 gallon steel drum.
14. Liquid Products Only: List the density i.e., the pound weight of one gallon of the formulated product or list the specific gravity.
Solid Products Only: Total weight per cubic foot of the formulated material.
The Application Package should contain the following:
A cover letter describing the type of registration action requested and what is being submitted to DPR.
The Application Package shall contain the following:
A completed application form (pages 1, 2, 5). In lieu of the
One copy of all data submitted by the applicant to U.S. EPA
Product Formulation Information (p.5), the U.S. EPA Confidential
to support this product.
Statement of Formula may be submitted.
One copy of the data required by California regulations (Title
An application fee of $1150 is required for new products,
3, California Code of Regulations §6170).
additional brand names, master labels, product transfers, and
company ownership changes. Make check or money order
In lieu of submitting data pursuant to section 6170 (a) and
payable to “Department of Pesticide Regulation.”
(b), an applicant for registration or amendment may
reference appropriate data previously submitted to the
Director or a pesticide product(s) previously approved by
Six (6) copies of the product labeling. Typescript labeling may
the Director that would be subject to some or all of the same
be submitted if printed labels are not yet available. Printer's
data requirements as applicable to the applicant’s product.
proofs or final printed labels are required prior to issuance of a
NOTE: Pursuant to FAC §12811.5, applicants that rely upon data
Certificate of Registration.
owned by another company may have certain obligations to the
data owner in specifically defined situations. For further
Copy of the U.S. EPA correspondence accepting the product
information, please refer to
transfer, company ownership, and/or name change.
<http://www.cdpr.ca.gov/docs/legbills/ab1011/
resource.htm>
Copy of U.S. EPA stamped accepted label, acceptance letter,
and U.S. EPA Notice of Registration, if applicable.
Interim registration applications (FAC §13161 et seq.),
require an additional $5,000 fee.
State of California
Department of Pesticide Regulation
Additional Registration Information
Application for Pesticide Registration
DPR REG-030 (Rev. 10/15)
Page 4 of 6
Certificate of Registration / Acceptance
If your product is registered, a Certificate of Registration (license) will be issued to you, authorizing sales for the remainder
of the calendar year. Pesticide products may not be offered for sale until a Certificate of Registration has been issued.
If revised labeling is accepted for a registered product, the applicant will receive a letter of acceptance and a copy of the
product labeling stamped "Labeling Acceptable." The Department of Pesticide Regulation, Pesticide Registration Branch,
must accept all labeling to be used in connection with the sale of a product prior to sale or use of the product.
Renewal of Registration
In October of each year, you will be sent an Application for Renewal of Pesticide Registration, listing all currently
registered products. To apply for renewal of these products, registrants must sign and return the form with the appropriate
fee ($1150 per product). A penalty is assessed on all renewal requests received after January 31. Licenses will be
renewed when the fees are processed by DPR and are not retroactive to January 1.
EXTRACTS
Copies of extracts from the Food and Agricultural Code and the California Code of Regulations dealing with pesticide
registration may be obtained by writing to:
Department of Pesticide Regulation
Pesticide Registration Branch
P.O. Box 4015
Sacramento, California 95812-4015
Information Available on the Internet
Information about the California laws and regulations governing pesticide registration, as well as DPR notices, policies,
and procedures is available on the Internet at <http://www.cdpr.ca.gov>. Information on currently registered products,
registrants, telephone numbers, and e-mail addresses for DPR staff, and other information are also available at this site.
Persons interested in receiving notices specific to registration issues should subscribe to the e-mail list or access the
“California Notices to Registrants” web page found on DPR’s website. To subscribe to “California Notices to Registrants”
for e-mail delivery, visit the E-List page at <http://www.cdpr.ca.gov/docs/listserv/listdesc.htm>, and click on the subscribe
link under the list name. You will receive an e-mail, welcoming you to the list. To access new and historical notices via the
Internet, see <http://www.cdpr.ca.gov/docs/canot/camenu.htm>.
Product Formulation Information
State of California
Department of Pesticide Regulation
See page 6 for instructions. (U.S. EPA Confidential Statement of Formula may be submitted in lieu of this page)
Application for Pesticide Registration
DPR REG-030 (Rev. 10/15)
1. Brand Name: ___________________________________
3. U.S. EPA/Calif. Reg. No. (if assigned) :_______________________
Page 5 of 6
2. Firm Name: ______________________________________________________________ 4. pH (if water soluble liquid) _________
5. Active Ingredient
6. Chemical
7. Brand name of source
8. EPA Reg. No.
9. Percent by
10. Percent by
Give common chemical name for each active
Abstracts Service
product for active ingredient
of source product
weight of source
weight of active
ingredient listed on the label. Microbials should show
(CAS) (or ATCC)
product in
ingredient in
genus, species, and strain.
No.
formulated product.
formulated
product.
13. Brand name of source
11. Inert Ingredient (common chemical name)
12. Chemical
14. Purpose in
15. Percent by
16. Percent by
product for inert ingredient.
weight of source
weight of inert
Abstracts Service
formulation.
product in
ingredient in
(CAS) No.
formulated product.
formulated
product.
0.00
0.00
Total _________
Total __________
If space is not sufficient, attach additional pages. Inert ingredients information given on this form is considered to be confidential
business information and is protected from disclosure under the California Public Records Act (Gov. Code §6254.2(l)). You may
Columns 9 + 15
Columns 10+16
submit a copy of your U.S. EPA Confidential Statement of Formula in lieu of this page.
=100.00%
=100.00%
Page of 6