Post Pesticide Application Data Submission Form

Within 48 hours, following completion of treatment, please provide a copy of your pesticide application data using this form.

Before submitting this form, please ensure that the information is correct. Submit one form for each application.

Please note, this data will be included in summary form in the City’s IPM Policy C501A Annual report and will be publically available.

��ϲ�� Project Information

Application Notification Reference #

��ϲ�� Contract Manager, Project Manager, or ��ϲ�� Senior Landscape Specialist for Private Development Email:

Only @edmonton.ca addresses.

��ϲ�� Contract Number or Servicing Agreement:

��ϲ�� Project Name and where applicable Neighbourhood/ Stage:

Contractor / Applicator Information

Contractor Name:

Certified Applicator Name:

Certified Applicator Licence Number:

Certified Applicator Licence Expiry Date:

Name of Representative Completing Form:

Representative's Phone Number:

Representative's Email Address:

Application Information

Treatment Site Address or Legal Land Description:

Size of Treatment Area:

Date

Pest Control Information

Pest to be Controlled and Host Plant if applicable:

Pesticide Name:

PCP Number:

Total Concentrate Product(s) Used (to Label Instruction):

Where label instructions include dilution, report only the amount of concentrate used.

Units:

FOIP Statement

This personal information is being collected under the authority of section 33(c) of the Freedom of Information and Protection of Privacy (FOIP) Act. The ��ϲ�� will use this information for purposes necessary to and consistent with administering the Contractor’s Environmental Responsibility Package, implementation of the Integrated Pest Management Policy C501A, and administration of the Pesticide Exemption Program. Personal information in the custody or under the control of the City is protected in accordance with the privacy provisions of FOIP. If you have any questions regarding the collection or use of this information, please contact the Melissa Brown, Environmental Manager, 9th Floor, 10111 104 Ave NW, ��ϲ��, AB T5J 0J4, 780-292-1132.

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