Form DPR-REG-028A "Experimental Pesticide Use Report" - California

What Is Form DPR-REG-028A?

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 April 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-028A 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-028A "Experimental Pesticide Use Report" - California

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State of California
Authorization Number
Department of Pesticide Regulation
Experimental Pesticide Use Report
DPR-REG-028a (Est. 4/15)
Experimental Pesticide Use Report
1. Researcher
Notice: This form must be
Researcher
returned to close out a
Return copy to:
Research Authorization.
Firm Name
If no trials were conducted,
RA Coordinator
check the “No Trials
Pesticide Registration Branch
Address
Conducted” box below,
Dept. of Pesticide Regulation
sign and return form. Please
P.O. Box 4015
City, State Zip
provide best contact
Sacramento, CA 95812-4015
Phone # /
number for follow up
Mobile Phone #
questions.
Use Data
2. Product Name
3. Formulation
4. Area or
5. Commodity or
6. Crop
7. County Where Trial Was
(only one)
Units Treated
Site Treated
Disposition
Conducted (only one)
(only one)
I
8. Active Ingredient(s)
9. Total Lbs. AI Used
2. Product Name
3. Formulation
4. Area or
5. Commodity or
6. Crop
7. County Where Trial Was
(only one)
Units Treated
Site Treated
Disposition
Conducted (only one)
(only one)
8. Active Ingredient(s)
9. Total Lbs. AI Used
2. Product Name
3. Formulation
4. Area or
5. Commodity or
6. Crop
7. County Where Trial Was
(only one)
Units Treated
Site Treated
Disposition
Conducted (only one)
(only one)
8. Active Ingredient(s)
9. Total Lbs AI Used
To add additional trial information, please use Experimental Pesticide Use Report (Continued) form DPR-REG-028b (Est. 4/15),
hereby incorporated by reference.
No Trials Conducted
Certification
Failure to comply with any of the conditions of this authorization pursuant to Title 3 California Code of Regulations §§ 6260-6272 could
result in revocation of the authorization and an administrative fine up to $5,000 for each time a condition or regulation is violated (Food
and Agricultural Code § 12999.5).
I certify that all the information contained within this form is true and complete to the best of my knowledge.
10. Signature of Researcher
Title
Date
Page 1 of ___
State of California
Authorization Number
Department of Pesticide Regulation
Experimental Pesticide Use Report
DPR-REG-028a (Est. 4/15)
Experimental Pesticide Use Report
1. Researcher
Notice: This form must be
Researcher
returned to close out a
Return copy to:
Research Authorization.
Firm Name
If no trials were conducted,
RA Coordinator
check the “No Trials
Pesticide Registration Branch
Address
Conducted” box below,
Dept. of Pesticide Regulation
sign and return form. Please
P.O. Box 4015
City, State Zip
provide best contact
Sacramento, CA 95812-4015
Phone # /
number for follow up
Mobile Phone #
questions.
Use Data
2. Product Name
3. Formulation
4. Area or
5. Commodity or
6. Crop
7. County Where Trial Was
(only one)
Units Treated
Site Treated
Disposition
Conducted (only one)
(only one)
I
8. Active Ingredient(s)
9. Total Lbs. AI Used
2. Product Name
3. Formulation
4. Area or
5. Commodity or
6. Crop
7. County Where Trial Was
(only one)
Units Treated
Site Treated
Disposition
Conducted (only one)
(only one)
8. Active Ingredient(s)
9. Total Lbs. AI Used
2. Product Name
3. Formulation
4. Area or
5. Commodity or
6. Crop
7. County Where Trial Was
(only one)
Units Treated
Site Treated
Disposition
Conducted (only one)
(only one)
8. Active Ingredient(s)
9. Total Lbs AI Used
To add additional trial information, please use Experimental Pesticide Use Report (Continued) form DPR-REG-028b (Est. 4/15),
hereby incorporated by reference.
No Trials Conducted
Certification
Failure to comply with any of the conditions of this authorization pursuant to Title 3 California Code of Regulations §§ 6260-6272 could
result in revocation of the authorization and an administrative fine up to $5,000 for each time a condition or regulation is violated (Food
and Agricultural Code § 12999.5).
I certify that all the information contained within this form is true and complete to the best of my knowledge.
10. Signature of Researcher
Title
Date
Page 1 of ___
State of California
Department of Pesticide Regulation
Pesticide Research Authorization
DPR-REG-028a (Est. 4/15)
If you need assistance with completing this report, contact the Research Authorization coordinator in the Pesticide Registration
Branch at (916) 445-4400. Or for additional information, refer to DPR’s Web site at
<http://www.cdpr.ca.gov/docs/registration/regforms/ra/ramenu.htm>. Each Research Authorization must be reported separately.
Do not combine more than one Research Authorization on the same report. Additional use information including product name,
formulation, commodity/site treated, county where trial was conducted, and/or active ingredients may be provided by filling out
and submitting to DPR form DPR-REG-028b (Est. 4/15).
1. Researcher:
Researcher in control of the pesticide research trial. Enter the firm name and mailing address. Return a copy to Plant Physiologist within two weeks
of the research authorization expiration date. If no trials were conducted, check the box labeled “No Trials Conducted,” sign and return form.
Use Data
2. Product Name: List the brand name or trade name of the pesticide product used. For subsequent products, you may add Roman numerals
(e.g., I, II, III, IV) to the first box under Product Name.
Do not report use of California registered test standard products used in accordance with label directions on this form. Instead, report use to the
Agricultural Commissioner in county where trials were conducted in accordance with pesticide use reporting regulations in Title 3 California Code
of Regulations §6626 and §6627.
3. Formulation (only one): List the formulation of the product used. Each product formulation must be entered separately. Use DPR-REG-028b,
Est. 4/15.
2
3
4. Area or Units Treated: Enter the area or total units treated. Examples include 6.5 acres, 5,000 ft
, 500 ft
, 45 hives, 90 trees.
5. Commodity or Site Treated (only one): Enter the name of the treated commodity (such as cherries), or treated sites (such as containers, trees,
fruit, animals, burrows, mounds, residences, hives, traps, de-greening room, greenhouses, towers). Only one commodity or site may be listed per
product name section.
6. Crop Disposition: Enter final disposition of the treated commodity/site: “harvest,” “destruct,” or “non-crop” sites (e.g., non-bearing trees, vines,
bare ground, roadsides, ditches, fence lines).
7. County Where Trial Was Conducted (only one): Enter the county name where trial was conducted. Only one county may be listed per product
name section. If the product was tested in multiple counties, list use in each county separately.
8. Active Ingredient(s): Enter each active ingredient in the product formulation.
9. Total Lbs. AI Used: Enter the total pounds of each active ingredient used per formulation/site/county. Amount of active ingredient other than
pounds must be converted.
Certification
10. Signature of Researcher/Title/Date: Responsible researcher shall sign, give title or profession, and date report before submitting to DPR.
Note: If multiple pages are used [form DPR-REG-027b (Est. 4/15)], please fill in the page numbers at the bottom right corner of the page to ensure
the submission is complete.
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