Form NA-00092-04 "Pesticide Use Approval" - Minnesota

What Is Form NA-00092-04?

This is a legal form that was released by the Minnesota Department of Natural Resources - a government authority operating within Minnesota. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • The latest edition provided by the Minnesota Department of Natural Resources;
  • 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 printable version of Form NA-00092-04 by clicking the link below or browse more documents and templates provided by the Minnesota Department of Natural Resources.

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NA-00092-04
Record No.
PESTICIDE USE APPROVAL
Location
One Time Application
Discipline
Reg. No.
Area No.
Unit Name
Unit No.
*
Program Project
Special Project
Type of Area (Campground, Trail, etc.)
Amount of Public Use
Legal Description: County, Twp, Rng, Sec.
*
If this box is marked, Legal Description is not required.
PROPOSED PESTICIDE USE
Product Name
Classification (Herbicide, Insecticide, etc.)
EPA Registration No.
Application Method
Formulation
Application Rate
Acres
Total Product
Proposed Application Date(s)
End of Project Date
Project Supervisor Name & Title
Estimated Cost
$
PURPOSE / NEED
Insect Control
Disease Control
Wildlife Habitat
Weed Control
Tree Release
Lake Rehabilitation
Noxius Weeds
Site Preparation
Crop Production
Other
:
(explain)
Need and concern (Why is this the preferred alternative? What is the consequence of “No Action” alternative?)
Target Species
EVALUATION
Proposed Evaluation
Responsible Person
Date
PREVIOUS CONTROLS ON TREATMENT SITE
Non-Pesticide Controls
Date
Pesticide Controls
Date
Treatment Limitations
Treatment Limitations
Results of Previous Controls
APPROVALS
Approval Signatures
Date
Approval Signatures
Date
NA-00092-04
Record No.
PESTICIDE USE APPROVAL
Location
One Time Application
Discipline
Reg. No.
Area No.
Unit Name
Unit No.
*
Program Project
Special Project
Type of Area (Campground, Trail, etc.)
Amount of Public Use
Legal Description: County, Twp, Rng, Sec.
*
If this box is marked, Legal Description is not required.
PROPOSED PESTICIDE USE
Product Name
Classification (Herbicide, Insecticide, etc.)
EPA Registration No.
Application Method
Formulation
Application Rate
Acres
Total Product
Proposed Application Date(s)
End of Project Date
Project Supervisor Name & Title
Estimated Cost
$
PURPOSE / NEED
Insect Control
Disease Control
Wildlife Habitat
Weed Control
Tree Release
Lake Rehabilitation
Noxius Weeds
Site Preparation
Crop Production
Other
:
(explain)
Need and concern (Why is this the preferred alternative? What is the consequence of “No Action” alternative?)
Target Species
EVALUATION
Proposed Evaluation
Responsible Person
Date
PREVIOUS CONTROLS ON TREATMENT SITE
Non-Pesticide Controls
Date
Pesticide Controls
Date
Treatment Limitations
Treatment Limitations
Results of Previous Controls
APPROVALS
Approval Signatures
Date
Approval Signatures
Date