Srpmic Agricultural Notification - Arizona Form 1080

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Salt River
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Pima-Maricopa Indian Community
Office Use Only
Environmental Protection & Natural Resources
10005 East Osborn Road, Scottsdale AZ 85256
Phone (480) 362-7500
E-mail: pesticides@srpmic-nsn.gov
Fax (480) 362-7584
SRPMIC Agricultural Notification - Arizona Form 1080
Seller _____________________________________________________
PSP # _________________________________
Date ___________________________
Grower ___________________________________________________
PGP # _________________________________
County _________________________
Pest Conditions
PMA Area
Yes
No
Harvest
Label and Worker Safety Reentry Interval
Label Days
Pesticide Application
Date
to Harvest
Date
Crop
Section
Township
Range
Acres
Crop
Section
Township
Range
Acres
Additional Field Descriptions ________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________ _
Rate & Unit
Dilution/
Total
EPA Registration Number
r
Active Ingredient
of Measure/Acre 100 GAL Chemical
Product/Brand Name
Total
Total Volume
Supplemental Label Required
AZDEQ Soil Applied
Air
Ground
Chemigation
Acres
Per Acre
Yes
No
Yes
No
Other: _________________________
Ground Water BMP
Yes
No
Label Restrictions/Special Instructions _________________________________________________________________________________________________ _
________________________________________________________________________________________________________________________________ _
________________________________________________________________________________________________________________________________ _
________________________________________________________________________________________________________________________________ _
________________________________________________________________________________________________________________________________ _
Custom Applicator ______________________________________________________ Delivery Location ____________________________________________
Grower/Pesticide Advisor's Signature __________________________________________________________
PGP/PCA Number_______________________
I, the undersigned, certify that the above instructions comply with SRO 60-79, Section 13-55 and SRO 60-79, Section 13.109.4 (A)(2).
SRO 60-79, Section 13.109.4 (A)(1) -- PESTICIDE POST-APPLICATION REPORT
I, the undersigned, certify that an application of pesticides was made by the designated applicator in strict compliance with the above recommendation and
instructions on the date and under the conditions specified below.
Equipment Tag #
Time(s) of Application
Wind Direction & Velocity
Date(s) Applied
Deviation From Instructions __________________________________________________________________________________________________________ _
________________________________________________________________________________________________________________________________ _
________________________________________________________________________________________________________________________________ _
Company Name ____________________________________________________________________________________PGP/CA # _______________________
Grower/Applicator Signature __________________________________________________________________________ PUP/PUC # ______________________
Print Operator(s)/Pilot Name __________________________________________________________________________
AAP # __________________________
THIS DOCUMENT MUST BE SUBMITTED TO THE SRPMIC-EPNR PESTICIDE OFFICE WITHIN 48-HOURS PRIOR TO THE APPLICATION.
Copy Distribution: Two Copies to Applicator -- One Copy to Advisor -- One Copy to Seller -- One Copy to Grower --One Copy to SRPMIC-EPNR

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