Form DPR-ENF-117 "School Site and Child Day Care Facility Pesticide Use Reporting by a Business" - California

What Is Form DPR-ENF-117?

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 December 1, 2016;
  • 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-ENF-117 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-ENF-117 "School Site and Child Day Care Facility Pesticide Use Reporting by a Business" - California

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SCHOOL SITE AND CHILD DAY CARE FACILITY
PESTICIDE USE REPORTING BY A BUSINESS
STATE OF CALIFORNIA
DEPARTMENT OF PESTICIDE REGULATION
DPR-ENF-117 (REV. 12/16)
PEST MANAGEMENT & LICENSING BRANCH
Page 1 of 2
APPLICATION YEAR BUSINESS REGISTRATION/LICENSE/CERTIFICATE #
BUSINESS/OPERATOR NAME
BUSINESS ADDRESS
CITY
STATE
ZIP CODE
BUSINESS PHONE NUMBER
Pest
Amount of Pesticide
Control
School CDS #/Child Day Care Facility #
County
Date & Time
Location
Manufacturer & Name of
EPA REG. Number on Label or
Product Used
Code
OR Name & Address AND Specify if
Code
Application
Product Applied
CA Reg. Number for adjuvants
(# from list on back)
School or Child Day Care Facility
(list on
Completed
(check for write in
(from list
(include alpha code, if listed)
unit from label)
back)
on back)
School
(vol.)
OZ
ML
PT
(wt.)
Day Care
GR
OZ
LB
School
(vol.)
OZ
ML
PT
(wt.)
Day Care
GR
OZ
LB
School
(vol.)
OZ
ML
PT
(wt.)
Day Care
GR
OZ
LB
School
(vol.)
OZ
ML
PT
(wt.)
Day Care
GR
OZ
LB
School
(vol.)
OZ
ML
PT
(wt.)
Day Care
GR
OZ
LB
REPORT PREPARED BY __________________________________________________________
DATE___________________________________
Report for the calendar year must be submitted by January 30th of the following year to School Pesticide Use Reporting, Department of Pesticide Regulation, P.O. Box 4015, Sacramento, CA 95812-4015
SCHOOL SITE AND CHILD DAY CARE FACILITY
PESTICIDE USE REPORTING BY A BUSINESS
STATE OF CALIFORNIA
DEPARTMENT OF PESTICIDE REGULATION
DPR-ENF-117 (REV. 12/16)
PEST MANAGEMENT & LICENSING BRANCH
Page 1 of 2
APPLICATION YEAR BUSINESS REGISTRATION/LICENSE/CERTIFICATE #
BUSINESS/OPERATOR NAME
BUSINESS ADDRESS
CITY
STATE
ZIP CODE
BUSINESS PHONE NUMBER
Pest
Amount of Pesticide
Control
School CDS #/Child Day Care Facility #
County
Date & Time
Location
Manufacturer & Name of
EPA REG. Number on Label or
Product Used
Code
OR Name & Address AND Specify if
Code
Application
Product Applied
CA Reg. Number for adjuvants
(# from list on back)
School or Child Day Care Facility
(list on
Completed
(check for write in
(from list
(include alpha code, if listed)
unit from label)
back)
on back)
School
(vol.)
OZ
ML
PT
(wt.)
Day Care
GR
OZ
LB
School
(vol.)
OZ
ML
PT
(wt.)
Day Care
GR
OZ
LB
School
(vol.)
OZ
ML
PT
(wt.)
Day Care
GR
OZ
LB
School
(vol.)
OZ
ML
PT
(wt.)
Day Care
GR
OZ
LB
School
(vol.)
OZ
ML
PT
(wt.)
Day Care
GR
OZ
LB
REPORT PREPARED BY __________________________________________________________
DATE___________________________________
Report for the calendar year must be submitted by January 30th of the following year to School Pesticide Use Reporting, Department of Pesticide Regulation, P.O. Box 4015, Sacramento, CA 95812-4015
STATE OF CALIFORNIA
DEPARTMENT OF PESTICIDE REGULATION
DPR-ENF-117 (REV. 12/16)
PEST MANAGEMENT & LICENSING BRANCH
Page 2 of 2
INSTRUCTIONS:
1. Each line is an individual pesticide application. Report only one schoolsite, date/time, and pesticide per line. Multiple pages will be needed
if you need to report more than 5 pesticide applications.
2. A name and address is required for each schoolsite. A cover sheet with all schoolsite names/addresses can be included with your report
to prevent repetitive writing/typing.
3. Applicators: If you are mixing a concentrate with a liquid, report the amount of concentrate applied. For products that don’t require dilution,
report the amount of finished product applied.
PEST CONTROL CODES:
Code 10 - Structural Pest Control .......................... includes pest control work performed within or on buildings or other structures
Code 30 - Landscape Maintenance Pest Control... includes pest control work performed on landscape plantings around buildings
Code 80 - Vertebrate Pest Control ......................... includes pest control work performed by public agencies or work under the supervision of the State or county agricultural commissioner
Code 91 - Nonfood / Nonfeed Fumigation................ includes pest control work performed on commodities such as mattresses, furniture, etc.
LOCATION CODES:
1
Administration Bldg
5
Cafeteria/Kitchen
9
Landscape (indoor)
13
Multipurpose Room
17
Vehicle
2
Athletic Field
6
Classroom
10
Landscape (outdoor)
14
Playground
18
Multiple Locations
3
Auditorium
7
Gymnasium
11
Library
15
Pool
19
Other (Please indicate)
4
Bldg, Exterior
8
Hardscape (parking lot, sidewalk, etc.)
12
Locker Room
16
Restroom
____________________
CALIFORNIA COUNTY CODES
11 - GLENN
21 - MARIN
01 - ALAMEDA
31 - PLACER
41 - SAN MATEO
51 - SUTTER
12 - HUMBOLDT
22 - MARIPOSA
02 - ALPINE
32 - PLUMAS
42 - SANTA BARBARA
52 - TEHAMA
13 - IMPERIAL
23 - MENDOCINO
03 - AMADOR
33 - RIVERSIDE
43 - SANTA CLARA
53 - TRINITY
14 - INYO
24 - MERCED
04 - BUTTE
34 - SACRAMENTO
44 - SANTA CRUZ
54 - TULARE
15 - KERN
25 - MODOC
05 - CALVERAS
35 - SAN BENITO
45 - SHASTA
55 - TUOLUMNE
16 - KINGS
26 - MONO
06 - COLUSA
36 - SAN BERNARDINO
46 - SIERRA
56 - VENTURA
17 - LAKE
27 - MONTEREY
07 - CONTRA COSTA
37 - SAN DIEGO
47 - SISKIYOU
57 - YOLO
18 - LASSEN
28 - NAPA
08 - DEL NORTE
38 - SAN FRANCISCO
48 - SOLANO
58 - YUBA
19 - LOS ANGELES
29 - NEVADA
09 - EL DORADO
39 - SAN JOAQUIN
49 - SONOMA
20 - MADERA
30 - ORANGE
10 - FRESNO
40 - SAN LUIS OBISPO
50 - STANISLAUS
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