Restricted Chemical Product (Rcp) Permit Application - Western Australia Department Of Agriculture And Food
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Please complete this application only if there is no current permit for the property,
or details of ownership, land use, risk, products or nominated parties recorded on
Print Form
the application for the current permit have changed.
Restricted Chemical Product (RCP) permit application
Applicant -
The applicant must be the owner/occupier of the land to be baited, their authorised agent or an authorised person.
Name
Applicant status
Owner
Contact Address
Occupier
Trading name (if applicable)
Telephone number
Authorised person
Fax/Email
Mobile
Agent (authority attached)
Property address
Postal address
Postcode
Nominated S7 Retailer / Licensed Pest Management Technician to supply products
Nominated S7 retailer/technician
License number
S7 retailer address
Postcode
Telephone
Fax
Email
Applicant Declaration
Remarks
I,
Attach a property map: include points below
where relevant and show all distances from bait
of
area.
to
request a permit to use restricted chemical products from
Highlight: all access/entry points.
•
and being over 18 years of age and the owner/occupier/authorised agent of the above land state that:
Indicate: roads & tracks used for baiting.
•
· the above information and the attached map is true and correct, and should the use of the
Indicate: water bodies and water courses.
•
recommended products on my property be approved.
♦
: constructed recreational sites.
•
I hereby agree to ensure that I and any person nominated as my agent, receiver or approved user for the
Shade in: sites or areas not to be baited.
•
purposes of this application is appropriately trained and/or authorised and shall comply with the relevant
: locations of dwellings (own & adjacent).
• X
code of practice and label directions of use particularly in respect to:
▲: proposed location of all poison warning signs
•
· neighbour notification, warning signs, distance restrictions, clean up after baiting and disposal of wastes,
Diagonal hatch: large properties may also
•
precautionary measures, storage and transport and record keeping; and
indicate general baiting area.
· will also comply with any and all additional conditions applied by the authorised risk assessment officer.
As the owner/occupier/approved agent of the above land I acknowledge that should the risk factors on this
Important - Please note
property change or any of the nominated persons/retailers change, I must inform an authorising officer and
Applications for permits must be paid PRIOR to
submit a revised baiting application form and property map.
processing. Once the application is submitted, an
invoice will be issued and the application will be
Print and sign
Signature
Date
processed when payment is confirmed.
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