"Restricted Use Pesticide Purchase Permit Application" - New York

Restricted Use Pesticide Purchase Permit Application is a legal document that was released by the New York State Department of Environmental Conservation - a government authority operating within New York.

Form Details:

  • Released on April 1, 2020;
  • The latest edition currently provided by the New York State Department of Environmental Conservation;
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DIVISION OF MATERIALS MANAGEMENT ● BUREAU OF PESTICIDES MANAGEMENT
RUPPA (04/20)
www.dec.ny.gov
Restricted Use Pesticide Purchase Permit
Application
The undersigned hereby applies for a Restricted Use Pesticide Purchase Permit for the purchase and use of restricted use pesticides pursuant to
Article 33 of the Environmental Conservation Law. Type or print clearly.
APPLICANT INFORMATION
1. Name of Applicant:
2. Mailing Address:
City:
State:
Zip Code:
3. Home Telephone Number:
4. Business Telephone Number:
5. E-mail address:
Agricultural Establishment Information
6: Name of Agricultural Establishment:
7. Address of Agricultural Establishment:
8. City:
State:
Zip Code:
9. County:
PESTICIDE INFORMATION
Product #1
Product #2
10.
Pesticide Name:
11.
Pesticide Manufacturer:
12.
Pesticide active ingredient(s):
13.
Pesticide EPA Registration No.:
14.
Crop treated:
15.
Target Pest:
16.
Application Rate
17.
Method of application:
18.
Number of acres to be treated:
19.
Number of applications anticipated this
year:
DIVISION OF MATERIALS MANAGEMENT ● BUREAU OF PESTICIDES MANAGEMENT
RUPPA (04/20)
www.dec.ny.gov
Restricted Use Pesticide Purchase Permit
Application
The undersigned hereby applies for a Restricted Use Pesticide Purchase Permit for the purchase and use of restricted use pesticides pursuant to
Article 33 of the Environmental Conservation Law. Type or print clearly.
APPLICANT INFORMATION
1. Name of Applicant:
2. Mailing Address:
City:
State:
Zip Code:
3. Home Telephone Number:
4. Business Telephone Number:
5. E-mail address:
Agricultural Establishment Information
6: Name of Agricultural Establishment:
7. Address of Agricultural Establishment:
8. City:
State:
Zip Code:
9. County:
PESTICIDE INFORMATION
Product #1
Product #2
10.
Pesticide Name:
11.
Pesticide Manufacturer:
12.
Pesticide active ingredient(s):
13.
Pesticide EPA Registration No.:
14.
Crop treated:
15.
Target Pest:
16.
Application Rate
17.
Method of application:
18.
Number of acres to be treated:
19.
Number of applications anticipated this
year:
20.
Container size available:
21.
Total amount of pesticide needed per
calendar year:
AFFIRMATION – Please check all boxes below:
22. I am aware that a permit will not be issued if this application is not complete. 
23. I am at least 17 years old. 
24. I regularly use and apply pesticides as a significant part of my gainful employment or livelihood at an
agricultural establishment. 
25. I understand that applying for a Restricted Use Pesticide Purchase Permit will subject the
establishment to inspection by the Bureau of Pesticides Management. 
26. I acknowledge that the information in this application is true and accurate and that any false
statements made herein are punishable as a Class A misdemeanor pursuant to Section 210.45 of the
New York Penal Law.
Signature
Date
MAIL OR EMAIL THE COMPLETED APPLICATION AND ATTACHMENTS TO THE APPROPRIATE REGIONAL DEC OFFICE LISTED
BELOW:
Region 1
Nassau, Suffolk
50 Circle Road, Stony Brook, NY 11790-3409 - (631) 444-0340
r1pesticides@dec.ny.gov
Region 2
New York City
1 Hunters Point Plaza, 47-40 21st Street, Long Island City, NY 11101-5407
(718) 482-4994
PesticidesR2@dec.ny.gov
Region 3
Dutchess, Orange,
21 South Putt Corners Road, New Paltz, NY 12561-1696 - (845) 256-3097
Putnam, Rockland,
catherine.ahlers@dec.ny.gov
Sullivan, Ulster,
Westchester
Region 4
Delaware, Green, Otsego,
1130 North Westcott Road, Schenectady, NY 12306 - (518) 357-2045
Schenectady, Albany,
mark.solan@dec.ny.gov
Schoharie, Montgomery,
Rensselaer, Columbia
Region 5
Clinton, Essex, Franklin,
232 Golf Course Road, Warrensburg, NY 12885 - (518) 623-1200
Fulton, Hamilton, Saratoga,
brian.primeau@dec.ny.gov
Warren, Washington
Region 6
Herkimer, Jefferson, Lewis,
Utica State Office Building, 207 Genesee Street, Utica, NY 13501
amy.ortlieb@dec.ny.gov
Oneida, St. Lawrence
(315) 793-2554;
Region 7
Broome, Cayuga, Chenango,
1285 Fisher Avenue, Cortland, NY 13045-1090 - (607) 753-3095
Cortland, Tioga, Onondaga,
jacqueline.lamb@dec.ny.gov
Oswego, Madison, Tompkins
Region 8
Chemung, Genesee,
6274 East Avon-Lima Road, Avon, NY 14414-9519 - (585) 226-2466
Livingston, Monroe, Ontario,
justin.schoff@dec.ny.gov
Orleans, Wayne, Schuyler,
Seneca, Steuben, Yates
Region 9
Allegany, Cattaraugus,
270 Michigan Avenue, Buffalo, NY 14203-2999 - (716) 851-7220
Niagara, Erie, Chautauqua,
robert.freese@dec.ny.gov
Wyoming
APPLICATION INSTRUCTIONS
Applicant Information
Block 1.
Enter your full name.
Block 2.
Enter your mailing address. This should be the address you use to receive your mail. Enter your city, two letter
state abbreviation, and zip code with zip extension.
Block 3.
Enter your home telephone number and area code.
Block 4.
Enter your business telephone number and area code.
Block 5.
Enter your e-mail address.
The issuance of a Pesticide Purchase Permit for the purchase and use of a restricted use pesticide may subject
you to an inspection by Bureau of Pesticides Management staff.
Block 6.
Enter the Name of the Agricultural Establishment.
Block 7.
Enter the physical address of the Agricultural Establishment.
Block 8.
Enter the city/town of the Agricultural Establishment.
Block 9.
Enter the county of the Agricultural Establishment.
Pesticide Information
Block 10.
Enter the name of the pesticide you would like to purchase. This is found on the pesticide container or can be
provided by the individual that sells the pesticide.
Block 11.
Enter the name of the pesticide manufacturer. This is found on the pesticide container or can be provided by the
individual that sells the pesticide.
Block 12.
Enter the pesticide active ingredient. This is found on the pesticide container or can be provided by the
individual that sells the pesticide.
Block 13.
Enter the pesticide EPA registration number. This is found on the pesticide container or can be provided by the
individual that sells the pesticide.
Block 14.
Enter the crop to be treated.
Block 15.
Enter the target pest.
Block 16.
Enter the application rate of the pesticide. For example, fluid ounces/gallon of water, or pints/acre. This is found
on the pesticide container or can be provided by the individual that sells the pesticide.
Block 17.
Enter the method of pesticide application. For example, you may be applying the pesticide using a boom
sprayer, an air blast sprayer, or some other method.
Block 18.
Enter the number of acres to be treated.
Block 19.
Enter the number of applications anticipated to be made with this product this year.
Block 20.
Enter the size of the container available
Block 21.
Enter the total amount of pesticide that will be purchased this year. This is based on container size that is
available. Add the unit of measure in pounds or gallons.
Affirmation
Block 22.
Check the box affirming that the application is filled out.
Block 23.
Check the box affirming the minimum age of the applicant.
Block 24.
Check the box affirming your eligibility to obtain a purchase permit.
Block 25.
Check the box indicating that you are aware that in applying for a Pesticide Purchase Permit for the purchase
and use of a restricted use pesticide, the applicator and the agricultural establishment is subject to an inspection
by The Department’s Bureau of Pesticides Management.
Block 26.
By signing this application you acknowledge that the information is true and accurate and are aware that any
false statements made on this application are punishable as a Class A misdemeanor pursuant to Section
210.45 of the New York Penal Law
Print then sign and date the form.
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