"Application for Pesticide Application Permit" - Prince Edward Island, Canada

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Application for
Pesticide Application Permit
Under section 35 of the Pesticide Control Act Regulations, a person who applies Schedule 1 pesticides or applies
pesticides to an open body of water, to control mosquitoes or biting flies within a designated protected zone, must hold a
Pesticide Application Permit.
Personal information on this form is collected under section 19 of the Pesticide Control Act Regulations as it relates directly
to and is necessary for an application for a Pesticide Application Permit. Personal information may be disclosed to third
parties in accordance with provincial legislation. If you have any questions about this collection of personal information, you
may contact the Pesticide Regulatory Program, 11 Kent Street, Jones Building, Charlottetown, PEI C1A 7N8,
(902) 368-5599.
Section 1 – Applicant Contact Information
Name:
Phone:
Fax:
Mailing Address:
Civic Address:
Postal Code:
Email:
Section 2 – Complete for Mosquito and Biting Fly Control
G New Permit
G Modification of Permit
Type of Application:
Existing Permit Number:
G Water Treatment
G Private Treatment
G Land Treatment
G Commercial Treatment
Treatment Type:
Applicators/Certificates (list all applicators)
Pesticide Applicator
Applicator Name
Certificate No.
Class
Treatment Details
Pest to Be
Proposed Date
Proposed Rate
Total Amount of
Treatment
Controlled
Pesticide Name
PCP* No.
of Treatment
of Application
Pesticide Used
1
2
3
4
5
* Pesticide Control Product Registration Number
Describe the process and level of community support for the program (attach separate sheet if required):
Are “Permission to Enter Private Property” authorizations required? Yes G
No G
If “Yes”, include authorizations with application.
Requirements:
A map (1:25,000 scale) must be attached and identify:
(a) all property lines, fields, and treatment areas; and
(b) all open bodies of water, as defined under the Prince Edward Island Pesticides Control Act; saltwater environments and
perimeter coastline.
Application for
Pesticide Application Permit
Under section 35 of the Pesticide Control Act Regulations, a person who applies Schedule 1 pesticides or applies
pesticides to an open body of water, to control mosquitoes or biting flies within a designated protected zone, must hold a
Pesticide Application Permit.
Personal information on this form is collected under section 19 of the Pesticide Control Act Regulations as it relates directly
to and is necessary for an application for a Pesticide Application Permit. Personal information may be disclosed to third
parties in accordance with provincial legislation. If you have any questions about this collection of personal information, you
may contact the Pesticide Regulatory Program, 11 Kent Street, Jones Building, Charlottetown, PEI C1A 7N8,
(902) 368-5599.
Section 1 – Applicant Contact Information
Name:
Phone:
Fax:
Mailing Address:
Civic Address:
Postal Code:
Email:
Section 2 – Complete for Mosquito and Biting Fly Control
G New Permit
G Modification of Permit
Type of Application:
Existing Permit Number:
G Water Treatment
G Private Treatment
G Land Treatment
G Commercial Treatment
Treatment Type:
Applicators/Certificates (list all applicators)
Pesticide Applicator
Applicator Name
Certificate No.
Class
Treatment Details
Pest to Be
Proposed Date
Proposed Rate
Total Amount of
Treatment
Controlled
Pesticide Name
PCP* No.
of Treatment
of Application
Pesticide Used
1
2
3
4
5
* Pesticide Control Product Registration Number
Describe the process and level of community support for the program (attach separate sheet if required):
Are “Permission to Enter Private Property” authorizations required? Yes G
No G
If “Yes”, include authorizations with application.
Requirements:
A map (1:25,000 scale) must be attached and identify:
(a) all property lines, fields, and treatment areas; and
(b) all open bodies of water, as defined under the Prince Edward Island Pesticides Control Act; saltwater environments and
perimeter coastline.
Section 3 – Complete for Application to Open Body of Water
G New Permit
G Modification of Permit
Type of Application:
Existing Permit Number:
G Private Treatment
G Commercial Treatment
Treatment Type:
Pesticide Applicator Certificate: Name:
Number:
Class:
Expiry date:
Treatment Details
Proposed
Proposed
Total Amount
Total Treatment Area
Pest to Be
Pesticide
Date of
Rate of
of Pesticide
G Acres
G Hectares
Treatment
Controlled
Name
PCP* No.
Treatment
Application
Used
1
2
3
4
5
* Pest Control Product Registration Number
Requirements:
A map (1:10,000 scale) must be attached and identify:
(a) all property lines, fields, and treatment areas; and
(b) all open bodies of water, as defined under the Prince Edward Island Pesticides Control Act; saltwater environments and
perimeter coastline.
Section 4 – Complete for Schedule 1 Pesticides (Soil Fumigant Formulations)
G New Permit
G Modification of Permit
Type of Application:
Existing Permit Number:
Pesticide Applicator Certificate:
Name:
Number:
Class:
Expiry date:
Treatment Details
Total Treatment Area
Property
G Acres
G Hectares
Identification No.
Field No.
Crop
Pesticide Name
PCP * No.
* Pest Control Product Registration Number
Time of Proposed Treatment:
G Spring
Proposed treatment date(s):
G Fall
Proposed treatment date(s):
Distance to Wells/Residences
Distance (m) to
Property
Nearest Well (Indicate
Distance (m) to Nearest
Distance (m) to Nearest
Identification No.
Field No.
Private or Municipal)
Occupied Habitation
Property Line
Requirements:
1.
An Environmental Farm Plan must be completed for all owned properties.
2.
Product use must be in compliance with the product label, and with all additional legal requirements, including the PEI
Environmental Protection Act and the PEI Agricultural Crop Rotation Act.
3.
A map (1:10,000 scale) must be attached and identify:
a. all property lines, fields, and treatment areas;
b. all occupied habitations within 1,000 metres of the treatment area;
c. all municipal and/or private drinking water wells within 1,000 metres of the treatment area; and
d. all open bodies of water, as defined under the PEI Pesticides Control Act; saltwater environments; and/or perimeter coastline.
4.
Application for a permit must be made at least four weeks in advance of anticipated or planned product application.
Section 5 – Complete for Application to Designated Protected Zone
Type of Application: G New Permit
G Modification of Permit
Existing Permit Number:
Pesticide Applicator Certificate
Name:
Number:
Class:
Expiry date:
Treatment Details
Total Treatment Area
Property
Rate of
Identification No.
Acres
Hectares
Pest*
Pesticide Name
PCP** No.
Application
* A Pesticide Application Permit will only be issued for the control of a noxious weed, as designated under the Weed Control
Act.
** Pest Control Product Registration Number
Requirements:
A map (1:10,000 scale) must be attached and identify:
(a)
all property lines, fields, and treatment areas; and
(b)
all open bodies of water, as defined under the Prince Edward Island Pesticides Control Act; saltwater environments and
perimeter coastline.
By signing below, I acknowledge that all information that I have provided is, to my knowledge, true and accurate, and that I
understand the above listed criteria for approval of a Pesticide Application Permit.
Applicant’s Signature:
Date:
• The application fee for a Pesticide Application Permit is $50 per permit.
• Payment must be received by the department before the application will be processed.
• A separate application is required for each Pesticide Application Permit.
Method of Payment (Check appropriate box)
Please forward application and payment to:
G Cheque
Department of Communities, Land and Environment
G Money Order
Pesticide Regulatory Program
G Cash or Debit Card
PO Box 2000, 11 Kent Street
G Credit Card
Charlottetown, PE C1A 7N8
Amount Enclosed: $________________
Tel: (902) 368-5599
Cheques and money orders should be made payable to the Minister of Finance.
Pesticide Application Permits will be mailed to the applicant’s address above.
Please allow two weeks for delivery.
15EN15-42284
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