"Restricted-Use Pesticide Permission Notice" - South Dakota

Restricted-Use Pesticide Permission Notice is a legal document that was released by the South Dakota Department of Agriculture - a government authority operating within South Dakota.

Form Details:

  • The latest edition currently provided by the South Dakota Department of Agriculture;
  • Ready to use and print;
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  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the South Dakota Department of Agriculture.

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Download "Restricted-Use Pesticide Permission Notice" - South Dakota

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RESTRICTED-USE PESTICIDE PERMISSION NOTICE
Date: _____________________
Name of Certified Applicator: _________________________________________
Address: _________________________________________________________
City: __________________________ State __________ Zip _______________
Certification Number _______________________________________________
Expiration Date of Certification: _______________________________________
Pesticide/Product Name ____________________________________________
Amount to be Picked up/Purchased ____________________________________
Date to be Picked up/Purchased ______________________________________
Individual who will be picking up and/or purchasing restricted-use pesticides to
be applied by me:
Name: __________________________________________________________
Address: _________________________________________________________
City: __________________________ State __________ Zip _______________
________________________________
(Certified Applicator Signature)
A copy of this notice is to be filed as part of the required restricted-use pesticide
dealer records.
RESTRICTED-USE PESTICIDE PERMISSION NOTICE
Date: _____________________
Name of Certified Applicator: _________________________________________
Address: _________________________________________________________
City: __________________________ State __________ Zip _______________
Certification Number _______________________________________________
Expiration Date of Certification: _______________________________________
Pesticide/Product Name ____________________________________________
Amount to be Picked up/Purchased ____________________________________
Date to be Picked up/Purchased ______________________________________
Individual who will be picking up and/or purchasing restricted-use pesticides to
be applied by me:
Name: __________________________________________________________
Address: _________________________________________________________
City: __________________________ State __________ Zip _______________
________________________________
(Certified Applicator Signature)
A copy of this notice is to be filed as part of the required restricted-use pesticide
dealer records.