Form DPR-PML-017C "Production Agriculture Monthly Pesticide Use Report" - California

What Is Form DPR-PML-017C?

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 August 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-PML-017C by clicking the link below or browse more documents and templates provided by the California Department of Pesticide Regulation.

ADVERTISEMENT
ADVERTISEMENT

Download Form DPR-PML-017C "Production Agriculture Monthly Pesticide Use Report" - California

616 times
Rate (4.8 / 5) 43 votes
STATE OF CALIFORNIA
DEPARTMENT OF PESTICIDE REGULATION
DPR-PML-017C (REV. 08/15) Page 1 of 2
PRODUCTION AGRICULTURE MONTHLY PESTICIDE USE REPORT
Submit to the Agricultural Commissioner within 10 days of the month following application.
2
1
Month
Year
Address
Operator (Grower)
City
Zip Code
Operator ID/Permit No.
6
4
5
7
3
Total Planted Acres/Units
County Number
Section
Township
Range
Site Identification No.
Base & Meridian
N
S
E
W
S
M
H
8
9
10
11
12
13
14
Commodity/Site Treated
Field Location
15
16
Date/Time
Acreage/
Pre-plant
Application Method
Block ID
EPA or State Registration Number
Total Product Used
Days
Rate
Dilution
Product and Manufacturer
Application
Units
(If Applicable)
(Check One)
(If Applicable)
(From Label)
Reentry
Per Acre
Completed
Treated
17
18
19
20
21
22
23
24
25
26
27
Ground
Air
Fume
LB OZ PT QT GA
Other
Ground
Air
Fume
LB OZ PT QT GA
Other
Ground
Air
Fume
LB OZ PT QT GA
Other
Ground
Air
Fume
LB OZ PT QT GA
Other
Ground
Air
Fume
LB OZ PT QT GA
Other
Ground
Air
Fume
LB OZ PT QT GA
Other
Report Prepared By
Date
Reviewed By
For Agency Use Only
Distribution: (1) CAC; (2,3) Applicator
SUBMIT TO AGRICUTURAL COMMISSIONER WITHIN 10 DAYS OF MONTH FOLLOWING APPLICATION
STATE OF CALIFORNIA
DEPARTMENT OF PESTICIDE REGULATION
DPR-PML-017C (REV. 08/15) Page 1 of 2
PRODUCTION AGRICULTURE MONTHLY PESTICIDE USE REPORT
Submit to the Agricultural Commissioner within 10 days of the month following application.
2
1
Month
Year
Address
Operator (Grower)
City
Zip Code
Operator ID/Permit No.
6
4
5
7
3
Total Planted Acres/Units
County Number
Section
Township
Range
Site Identification No.
Base & Meridian
N
S
E
W
S
M
H
8
9
10
11
12
13
14
Commodity/Site Treated
Field Location
15
16
Date/Time
Acreage/
Pre-plant
Application Method
Block ID
EPA or State Registration Number
Total Product Used
Days
Rate
Dilution
Product and Manufacturer
Application
Units
(If Applicable)
(Check One)
(If Applicable)
(From Label)
Reentry
Per Acre
Completed
Treated
17
18
19
20
21
22
23
24
25
26
27
Ground
Air
Fume
LB OZ PT QT GA
Other
Ground
Air
Fume
LB OZ PT QT GA
Other
Ground
Air
Fume
LB OZ PT QT GA
Other
Ground
Air
Fume
LB OZ PT QT GA
Other
Ground
Air
Fume
LB OZ PT QT GA
Other
Ground
Air
Fume
LB OZ PT QT GA
Other
Report Prepared By
Date
Reviewed By
For Agency Use Only
Distribution: (1) CAC; (2,3) Applicator
SUBMIT TO AGRICUTURAL COMMISSIONER WITHIN 10 DAYS OF MONTH FOLLOWING APPLICATION
Page 2 of 2
Use Report Completion Instructions
Production Agriculture Monthly Pesticide Use Report (DPR-PML-017C)
These instructions will assist you in completing this form. The completed forms must be submitted to the agricultural
th
commissioner in the county where the pest control work was performed by the 10
day of the month following the month of
application.
1 - 2. Enter the month and year of the pesticide applications.
3. Enter the Operator Identification Number/Restricted Material Permit Number assigned by the county agricultural
commissioner (CAC).
4 - 7. Identify the property operator (grower) and complete the address information.
8. Each commodity/site is assigned a unique identification number of one to eight characters. Enter this number exactly as
it was issued by the CAC.
9. Indicate the total planted acres, square feet or units at the treatment site. For pre-plant applications, enter the total
acreage, square feet or units to be treated.
10. Indicate the county number. This is available from the CAC.
11-13. Indicate the section, township, and range designation for each site that is treated. These designations must be the same as
those on your restricted materials permit or the Operator Identification form issued by the CAC. Otherwise, a coordinate
map showing the designations must be used to determine the appropriate information. The respective compass points
(e.g., “N” or “S”) should be checked as well.
14. There are only three base and meridians in California. One of the following code letters must be used to complete this
section: H-Humboldt, M-Mount Diablo, S-San Bernardino.
15. Enter the commodity/site treated. Identify the specific type of commodity (e.g., head lettuce, loose leaf lettuce, table
grapes or wine grapes). Do not use general groups such as “herbs,” “citrus” or “cole crops.”
16. Enter the location of the field treated. Use the system utilized by the CAC to designate the specific property treated.
17. For each pesticide application, indicate the date and hour it was completed. Use a 24-hour clock or military time (i.e.,
write 7:00 a.m. as 0700 hours).
18. For each application, report the total acreage treated. For band applications or strip spraying, report the total acreage at
the site. For spot spraying or partial applications (e.g., border treatments) indicate only the acreage that was actually
treated.
19. Check this box if the pesticide treatment is a pre-plant application.
20. Check the method of application that represents each application. If checking "FUME" (fumigation), include the four-
digit numeric field fumigation method (FFM) code.
21. Enter the appropriate number to identify a block within a field, if applicable.
22. Each pesticide is assigned an “EPA Regis. No.” or “Calif. Reg. No.” that appears on the label. Record the entire number
including the alpha code (e.g., “AA” or “ZA”) for each pesticide that is used. Do not use the “EPA Est. No.” Spreader
stickers, adjuvants, and drift control agents are registered as pesticides in California and must also be reported. Do not
report nutrients, fertilizers, buffers, etc., that have no EPA or California Registration Number. Record the number from
the label on the container that was used, not a number from a specimen label book.
23. Record the total amount of formulated (packaged) product that was used for each application. Do not report the total
mixture after dilution. Check only one unit of measure (if not on form, write it in this box). If necessary, decimals and
fractions may be used.
24. Enter the reentry interval as required by the pesticide label or regulation. (Optional)
25-26. Indicate the rate at which the pesticide was applied per acre (e.g., 1 pound in 100 gallons or 3 pints in 250 gallons).
(Optional)
27. Write in the name of the pesticide product and the manufacturer as identified on the label. Include the brand or trade
name and type of formulation if it is indicated on the label (e.g., Pestkill 30W, NoGro 6E, or Mildex SP).
Remember to sign and date the report. If you have any questions or need additional assistance in completing this form, please
contact your local CAC.
Page of 2