Form DPR-REG-030 Product Formulation Information - California

Form DPR-REG-030 or the "Product Formulation Information" is a form issued by the California Department of Pesticide Regulation.

Download a PDF version of the Form DPR-REG-030 down below or find it on the California Department of Pesticide Regulation Forms website.

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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%
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%
State of California
Department of Pesticide Regulation
Instructions for Product Formulation Information
Application for Pesticide Registration
DPR-REG-030 (Rev. 10/15)
Page 6 of 6
You can submit either page five of the California application DPR-REG-39-030 or a copy of your U.S. EPA Confidential Statement of Formula Form. Applications with incomplete
product formulation information cannot be processed, and the first page will be returned.
5.
Active Ingredient: List each active ingredient in this formulation as it appears on the label. Please list all active ingredients from one source product together for ease of
calculation of percentages.
6.
CAS No.:
The CAS Number may be obtained from the Chemical Abstract Service of the American Chemical Society, P.O. Box 3012, Columbus, Ohio, 43210.
Microorganisms should be identified by ATCC (American Type Culture Collection) or other recognized type culture collection number.
Name of Source Product: The name of the product which provides that active ingredient in the formulation.
7.
9.
Percent By Weight of Source Product in Formulated Product: Each source product listed in Column #7 must have a value in Column #9. For example, if active ingredient
A and active ingredient B are both from the same source product which makes up 50% of the formulated product, the single entry in Column 9 is 50%.
10.
Percent By Weight of Active Ingredient in Formulated Product: This percentage should be identical to that given on the labeling.
11.
Inert Ingredient: List each inert ingredient component in this formulation. NOTE: If you do not know the identity of an inert ingredient in your product, have your supplier
submit the chemical name of each inert ingredient, source product name, purpose in formulated product and percent by weight of the source product in the formulated product
directly to this office, with reference to your firm name, your product brand name and EPA Reg. No.
13.
Brand Name of Source Product: The name of the product which is the source of the inert ingredient listed in Column #11.
15.
Percent by Weight of Source Product in Formulated Product: Give the percentage by weight of each SOURCE PRODUCT in the formulated product. If the percent of a
source product is already listed in column #9, do not list the same figure again in column #15.
Percent by Weight of Inert Ingredient in the Formulated Product: The percentage by weight of the inert ingredient in column #11 in the formulated product.
16.
5. Active Ingredient
6. Chemical
7. Brand name of source
8. EPA Reg. No.
9. Percent by weight
10. Percent by
Give common chemical name for each active
Abstracts Service
product for active ingredient
of source
of source product
weight of active
ingredient listed on the label. Microbials should show
(CAS) (or ATCC)
product
in the formulated
ingredient in
genus, species, and strain.
No.
product.
formulated product.
pyrethrins
121-21-1
Pyrotech Concentrate
123-123
50.000%
0.010%
piperonyl butoxide
51-03-6
0.005%
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 the
ingredient in the
(CAS) No.
formulated product.
formulated product.
inerts from PyroTech Concentrate
-
Pyrotech Concentrate
inerts from
-
49.985 %
technical
petroleum distillate
8002-05-9
SoluSolv
diluent
50.000%
50.000%
TOTAL Columns 9 +
TOTAL Columns
15 =100.00%
10+16=100.00%
U.S. EPA Confidential Statement of Formula Form: If you submit a copy of the U.S. EPA Confidential Statement of Formula, you should ensure that source products are
adequately identified. Sources of active ingredient must be identified by U.S. EPA registration number. If an active ingredient source product is not separately registered in
California, information concerning the composition of this product will be required.

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