Form Doh-4212 - Emergency Pesticide Application Notification Exemption Reporting Form - New York State Department Of Health Page 2
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2Address of emergency pesticide application:
Street address
________________________________________________________________
________________________________________________________________
City, state, zip code
___________________________________ ______________ ____________
Telephone number
________________________________________________________________
County
________________________________________________________________
Property type
________________________________________________________________
(e.g., school, private residence, daycare facility, etc.)
Specific location of application on property
________________________________________________________________
(e.g., backyard by sandbox)
Approximate area covered by application
________________________________________________________________
(e.g., 100 square feet)
Product name(s) of
U.S. Environmental Protection
Amount of product(s) applied,
Active ingredient(s) in
pesticide(s) applied
Agency registration
expressed as undiluted material
product(s)
number(s) of product(s)
Description of situation that required the emergency application
______________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Description of any notification provided in this case to persons in the vicinity of the application and to other persons
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
PLEASE SEND COMPLETED FORM TO:
OFFICE USE ONLY
New York State Department of Health
Bureau of Toxic Substance Assessment
Date received
__________________________
Attention: Emergency Notification Exemption Staff
547 River Street, Room 330
Method of transmission
Troy, NY 12180-2216
__________________________
Fax - (518) 402-7819
Incident number
__________________________
DOH-4212 (9/01)
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