Form DPR-ENF-227 "Fumigant Management Plan (Field Fumigation)" - California

What Is Form DPR-ENF-227?

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 December 1, 2012;
  • 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-ENF-227 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-ENF-227 "Fumigant Management Plan (Field Fumigation)" - California

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State of California
Department of Pesticide Regulation
Enforcement Branch
FUMIGANT MANAGEMENT PLAN (FIELD FUMIGATION)
PAGE
OF
DPR-ENF-227 (Est. 12/12)
Page 1 of 6
--
Address ALL Fumigant Management Plan Labeling Requirements
--
A. Supervising Certified Applicator On-Site
NAME
INDIVIDUAL LICENSE NUMBER
LICENSE / CERTIFICATE TYPE
QAL SUBCATEGORY O
QAC SUBCATEGORY O
PEST CONTROL BUSINESS NAME
PEST CONTROL BUSINESS LICENSE NUMBER
PAC* (Complete section below)
DATE OF TRAINING
LOCATION OF TRAINING (Number and Street, City, State, ZIP Code OR Web Site)
ACTIVE INGREDIENT(S)
B. Owner / Operator of the Application Block Property
NAME
TELEPHONE NUMBER (Include Area Code)
PERMIT NUMBER
ADDRESS (Number and Street, City, State, ZIP Code)
C. County / Tribal Notification
COUNTY TO WHICH NOTICE OF INTENT WAS SUBMITTED
DATE NOTICE OF INTENT APPROVED
TRIBAL LEAD AGENCY (If applicable)
NAME OF PERSON NOTIFIED
DATE NOTIFIED
D. Recordkeeping
CHECK HERE IF THE OWNER/OPERATOR OF THE APPLICATION BLOCK HAS BEEN INFORMED THAT HE/SHE, AS WELL AS THE CERTIFIED APPLICATOR,
MUST KEEP A SIGNED COPY OF THE SITE-SPECIFIC FUMIGANT MANAGEMENT PLAN AND POST-APPLICATION SUMMARY FOR 2 YEARS FROM THE DATE OF
APPLICATION.
E. General Site Information
ADDRESS OF APPLICATION BLOCK (Number and Street, City, State, ZIP Code)
SITE IDENTIFICATION NUMBER
BLOCK NUMBER
BLOCK SIZE (ACRES)
SITE MAP, AERIAL PHOTOGRAPH ATTACHED TO THE FMP, OR DETAILED SKETCH BELOW THAT SHOWS APPLICATION BLOCK LOCATION, APPLICATION BLOCK
DIMENSIONS, BUFFER ZONE DIMENSIONS, PROPERTY LINES, ROADWAYS, RIGHTS-OF-WAYS, SIDEWALKS, PERMANENT WALKING PATHS, BUS STOPS, NEARBY
APPLICATION BLOCKS, SURROUNDING STRUCTURES (OCCUPIED AND UNOCCUPIED), LOCATIONS OF BUFFER ZONE SIGNS, LOCATIONS OF DIFFICULT TO
EVACUATE SITES WITH DISTANCES FROM THE APPLICATION BLOCK INDICATED, AND ANY OTHER SITE DETAILS REQUIRED BY PRODUCT LABELING.
CHECK HERE IF MAP AND SITE INFORMATION ARE ATTACHED
(Continued on following page)
State of California
Department of Pesticide Regulation
Enforcement Branch
FUMIGANT MANAGEMENT PLAN (FIELD FUMIGATION)
PAGE
OF
DPR-ENF-227 (Est. 12/12)
Page 1 of 6
--
Address ALL Fumigant Management Plan Labeling Requirements
--
A. Supervising Certified Applicator On-Site
NAME
INDIVIDUAL LICENSE NUMBER
LICENSE / CERTIFICATE TYPE
QAL SUBCATEGORY O
QAC SUBCATEGORY O
PEST CONTROL BUSINESS NAME
PEST CONTROL BUSINESS LICENSE NUMBER
PAC* (Complete section below)
DATE OF TRAINING
LOCATION OF TRAINING (Number and Street, City, State, ZIP Code OR Web Site)
ACTIVE INGREDIENT(S)
B. Owner / Operator of the Application Block Property
NAME
TELEPHONE NUMBER (Include Area Code)
PERMIT NUMBER
ADDRESS (Number and Street, City, State, ZIP Code)
C. County / Tribal Notification
COUNTY TO WHICH NOTICE OF INTENT WAS SUBMITTED
DATE NOTICE OF INTENT APPROVED
TRIBAL LEAD AGENCY (If applicable)
NAME OF PERSON NOTIFIED
DATE NOTIFIED
D. Recordkeeping
CHECK HERE IF THE OWNER/OPERATOR OF THE APPLICATION BLOCK HAS BEEN INFORMED THAT HE/SHE, AS WELL AS THE CERTIFIED APPLICATOR,
MUST KEEP A SIGNED COPY OF THE SITE-SPECIFIC FUMIGANT MANAGEMENT PLAN AND POST-APPLICATION SUMMARY FOR 2 YEARS FROM THE DATE OF
APPLICATION.
E. General Site Information
ADDRESS OF APPLICATION BLOCK (Number and Street, City, State, ZIP Code)
SITE IDENTIFICATION NUMBER
BLOCK NUMBER
BLOCK SIZE (ACRES)
SITE MAP, AERIAL PHOTOGRAPH ATTACHED TO THE FMP, OR DETAILED SKETCH BELOW THAT SHOWS APPLICATION BLOCK LOCATION, APPLICATION BLOCK
DIMENSIONS, BUFFER ZONE DIMENSIONS, PROPERTY LINES, ROADWAYS, RIGHTS-OF-WAYS, SIDEWALKS, PERMANENT WALKING PATHS, BUS STOPS, NEARBY
APPLICATION BLOCKS, SURROUNDING STRUCTURES (OCCUPIED AND UNOCCUPIED), LOCATIONS OF BUFFER ZONE SIGNS, LOCATIONS OF DIFFICULT TO
EVACUATE SITES WITH DISTANCES FROM THE APPLICATION BLOCK INDICATED, AND ANY OTHER SITE DETAILS REQUIRED BY PRODUCT LABELING.
CHECK HERE IF MAP AND SITE INFORMATION ARE ATTACHED
(Continued on following page)
FUMIGANT MANAGEMENT PLAN (FIELD FUMIGATION)
DPR-ENF-227 (Est. 12/12) (Reverse)
Page 2 of 6
PAGE
OF
F. General Application Information
PRODUCT NAME
U.S. EPA REGISTRATION NUMBER
TARGET APPLICATION DATE / WINDOW
APPLICATION RATE (POUNDS OR GALLONS OF PRODUCT / TREATED AREA)
WEATHER FORECAST REVIEWED
YES
APPLICATION METHOD
FLOOD
SPRINKLER
*
SPRAY BLADE DEPTH (In.)
DRIP DEPTH (In.)
DRENCH
SHANK DEPTH (Inches)
ROTARY TILL DEPTH (In.)
OTHER (Specify)
WATER PRESSURE (Pounds per square inch)
NOZZLE SIZE
LENGTH / LINE
IRRIGATION RATE (Inches / hr.)
IRRIGATION SET NUMBER
ACRES TREATED / SET
LINES / SET
TREATMENT TYPE (Mark as applicable)
BROADCAST (Entire field)
ROWS (Flat fume)
STRIP
RAISED BEDS
TREE HOLES
OTHER
G. Emergency Response Plan
EMERGENCY TELEPHONE NUMBER(S)
COUNTY AGRICULTURAL COMMISSIONER OFFICE TELEPHONE NUMBER (Include Area Code)
PROPERTY OPERATOR TELEPHONE NUMBER (Include Area Code)
PROPERTY OPERATOR NAME
PROPERTY OPERATOR ADDRESS (Number and Street, City, State, ZIP Code)
CERTIFIED APPLICATOR NAME
CERTIFIED APPLICATOR TELEPHONE NUMBER (Include Area Code)
CERTIFIED APPLICATOR ADDRESS (Number and Street, City, State, ZIP Code)
LOCATION OF ON-SITE TELEPHONE(S)
DESCRIPTION OF HOW COMMUNICATION WILL TAKE PLACE BETWEEN THE CERTIFIED APPLICATOR AND OTHER PERSONS
DESCRIPTION OF EVACUATION ROUTES
EMERGENCY PROCEDURES / RESPONSIBILITIES IN CASE OF AN INCIDENT, EQUIPMENT/TARP/SEAL FAILURE, COMPLAINTS OR ELEVATED AIR CONCENTRATION LEVELS SUGGESTING
POTENTIAL PROBLEMS, OR OTHER EMERGENCIES
H. Communication Plan for Certified Applicator / Property Operator / Handlers
ON-SITE COMMUNICATION AND HAZARD COMMUNICATION CONFORMS TO
MSDS AND LABELS FOR ALL PESTICIDES APPLIED ARE AVAILABLE ON-SITE
3 CCR SECTIONS 6618, 6619, 6723, AND 6723.1 AND THIS FUMIGATION PLAN
YES
YES
DESCRIBE ANY INSTRUCTIONS ABOUT POST-APPLICATION ACTIVITIES THAT THE CERTIFIED APPLICATOR COMMUNICATED TO THE PROPERTY OPERATOR / OWNER AND/OR TO HANDLERS.
INCLUDE THE NAME AND TELEPHONE NUMBER OF THE PROPERTY OPERATORS OR HANDLERS CONTACTED BY THE CERTIFIED APPLICATOR AND DATE CONTACTED.
I. Respiratory Program
WRITTEN RESPIRATORY PROGRAM DOCUMENT IS:
ATTACHED
ON FILE AT BUSINESS HEADQUARTERS*
TELEPHONE NUMBER (Include Area Code)
*BUSINESS HEADQUARTERS ADDRESS (Number and Street, City, State, ZIP Code)
FUMIGANT MANAGEMENT PLAN (FIELD FUMIGATION)
DPR-ENF-227 (Est. 12/12)
Page 3 of 6
PAGE
OF
J. Soil Conditions (immediately prior to application)
SOIL MOISTURE / DEPTH
SOIL MOISTURE METHOD USED
SOIL TEXTURE
SOIL TEMPERATURE °F / DEPTH
K. Tarp Plan
CHECK IF TARPS ARE NOT USED
TARP TYPE (Mark as applicable)
SEMI-VIRTUALLY IMPERMEABLE
HIGH BARRIER
TOTALLY IMPERMEABLE (TIF)
VIRTUALLY IMPERMEABLE (VIF)
(SIF)
HIGH-DENSITY POLYETHYLENE
OTHER (Specify)
(HDPE)
TARP MANUFACTURER AND BRAND NAME
LOT NUMBER
THICKNESS
TARP REPAIRS BY
TARP CHECK SCHEDULE
MINIMUM SIZE OF DAMAGE TO BE REPAIRED
FACTORS THAT DETERMINE WHEN TARP WILL BE REPAIRED
PERSON RESPONSIBLE FOR CUTTING TARPS
TARP CUTTING SCHEDULE / TARGET DATE
TARP CUTTING METHOD
PERSON RESPONSIBLE FOR REMOVING TARPS
TARP REMOVAL SCHEDULE / TARGET DATE
TARP REMOVAL METHOD
L. Buffer Zone Information
BUFFER ZONE DISTANCE
CREDITS APPLIED
MEASUREMENTS TAKEN TO SUPPORT THE CREDITS (If applicable)
ARE THERE AREAS IN THE BUFFER ZONE THAT ARE NOT UNDER THE CONTROL OF THE OWNER OF THE APPLICATION BLOCK?
YES
NO
IF YES, ATTACH A DESCRIPTION OR MAP OF THE AREAS, AND ATTACH THE WRITTEN AGREEMENT(S) FROM THE OWNERS /
OPERATORS OF THOSE AREAS.
M. Posting Fumigant-Treated Area
PERSON(S) POSTING AND REMOVING SIGNS
POSTING CONFORMS TO 3 CCR SECTION 6776
YES
DATE OF POSTING
DATE OF REMOVAL
LOCATION OF TREATED AREA SIGNS
N. Posting Buffer Zone
PERSON(S) POSTING AND REMOVING SIGNS
POSTING COMPLIES WITH LABEL REQUIREMENTS
YES
DATE OF POSTING
DATE OF REMOVAL
LOCATION OF BUFFER ZONE SIGNS
FUMIGANT MANAGEMENT PLAN (FIELD FUMIGATION)
DPR-ENF-227 (Est. 12/12)
Page 4 of 6
PAGE
OF
O. Air Monitoring Plan
WHEN AIR MONITORING IS REQUIRED. DIRECT READ DETECTION MONITORING DEVICE TO BE USED:
DRAEGER
MATHESON-KITAGAWA
SENSIDYNE
OTHER
WHEN SENSORY IRRITATION IS EXPERIENCED, OPERATIONS WILL:
CEASE; PERSONNEL WILL BE WITHDRAWN FROM THE SITE
CONTINUE WITH HANDLERS WEARING AIR-PURIFYING RESPIRATORS
WHEN NECESSARY, AIR MONITORING WILL BE PERFORMED BY
(Address and telephone number available on file at the business)
WHEN NECESSARY, THE FOLLOWING REPRESENTATIVE HANDLER TASKS WILL BE MONITORED
THE TIMING OF THE MONITORING THAT WILL BE PERFORMED IS AS FOLLOWS
P. Emergency Preparedness and Response Measures
CHECK HERE IF NOT APPLICABLE
IF EMERGENCY PREPAREDNESS AND RESPONSE MEASURES ARE REQUIRED, CHOOSE ONE OF THE TWO FOLLOWING OPTIONS:
OPTION 1: FUMIGANT SITE MONITORING (If applicable)
NAME OF PERSON MONITORING
METHOD OF MONITORING:
SENSORY IRRITATION
MECHANICAL DEVICE (Required for methyl bromide formulations with less than 20% chloropicrin)
LOCATIONS AND TIMES MONITORING WILL BE PERFORMED:
OPTION 2: RESPONSE INFORMATION FOR NEIGHBORS (If applicable)
NAME OF PERSON PROVIDING THE INFORMATION
TELEPHONE NUMBER OF PERSON PROVIDING THE INFORMATION (Include Area Code)
PROVIDE LIST OF RESIDENCES AND BUSINESSES INFORMED
Q. Difficult to Evacuate Sites
DIFFICULT TO EVACUATE SITES INCLUDE: PRE-K TO GRADE 12 SCHOOLS, STATE-LICENSED DAY CARE CENTERS, NURSING HOMES, ASSISTED LIVING FACILITIES, HOSPITALS, IN-PATIENT
CLINICS, AND PRISONS. CHECK ALL THAT APPLY:
WITHIN 1/8 MILE
WITHIN 1/4 MILE
SHOWN ON MAP
NOT APPLICABLE
FUMIGANT MANAGEMENT PLAN (FIELD FUMIGATION)
DPR-ENF-227 (Est. 12/12)
Page 5 of 6
PAGE
OF
R. Other Good Agricultural Practices
DESCRIPTION OF ALL OTHER APPLICABLE GOOD AGRICULTURAL PRACTICES (GAP)
DESCRIPTION OF MEASUREMENTS AND DOCUMENTATION ENSURING THAT GAPS ARE ACHIEVED
S. Other R equirements
RECORD ALL OTHER INFORMATION REQUIRED IN PRODUCT-SPECIFIC FUMIGANT MANAGEMENT PLAN LABELING
T. Attachments
SITE MAP, AERIAL PHOTOGRAPH, OR DETAILED SKETCH
WRITTEN RESPIRATORY PROGRAM
WRITTEN AGREEMENT(S), IF THE BUFFER ZONE EXTENDS ONTO LAND NOT UNDER THE CONTROL OF THE OWNER OF THE APPLICATION BLOCK
COPY OF EMERGENCY PREPAREDNESS AND RESPONSE INFORMATION FOR NEIGHBORS
MITC CONTROL PLAN
OTHER (LIST)
Page of 6