Fill and Sign the Louisiana Department of Insurance Request for Waiver of Ldi La Form

(501) 225-1598 FORM 163 (REV. 5/2013) ARKANSAS STATE PLANT BOARD LICENSE APPLICATION TO OPERATE A SEED TREATER (License covers m ultiple treaters at plant location) __________________________________________________________(_____)________________ NAME IN WHICH LICENSE IS TO BE ISSUED (Company) PHONE ___________________________________________________________________________________________________________ MAILING ADDRESS CITY STATE ZIP Email address:____________________________________________________________________ STATE THE AMOUNT AND KIND OF SUBSTANCE(S) In OUNCES per Hundredweight You Intend Using for EACH KIND OF SEED: (See Example on Attached Additional page-provided if need more space) KIND of SEED YES Kind of Treatment (List Chemical to be used -each Fungicide, Pesticide, etc.) EPA Reg. Num ber RATE (List ounces per hundredweight Or per bushel) NO ____ ____ 1. DO YOU UNDERSTAND THAT YOU ARE RESPONSIBLE FOR KNOWING THE INFORMATION IN CIRCULAR 10: REGULATIONS ON THE SALE OF PLANTING SEED IN ARKANSAS, SECTIONS I & J? _____ _____ 2. DO YOU UNDERSTAND THAT EACH TREATED BAG OF SEED MUST BEAR A POISON LABEL TRULY AND CORRECTLY STATING THE CHEMICAL(S) WERE USED WERE IN ACCORDANCE WITH THE MANUFACTURER’S RECOMMENDATIONS, AND IN ADDITION, THE LABEL MUST HAVE THE NAME OF THE CHEMICAL(S) USED, AS WELL AS THE APPROPRIATE SIGNAL WORD AND PRECAUTIONARY STATEMENT? _____ _____ 3. DO YOU UNDERSTAND THAT IT IS ILLEGAL TO SELL, GIVE AWAY, OR USE TREATED SEED FOR ANY PURPOSE OTHER THAN PLANTING? _____ _____ 4. DO YOU UNDERSTAND THAT YOU MUST MAINTAIN COMPLETE RECORDS AS TO KINDS AND AMOUNTS OF CHEMICALS USED, DATES, AND ROUTINE INVOICE INFORMATION FOR A PERIOD OF TWO YEARS FROM THE DATE OF THE TREATMENT APPLICATION? _____ _____ 5. DO YOU UNDERSTAND THAT THE PLANT BOARD OR ITS’ REPRESENTATIVE MAY INSPECT YOUR RECORDS DURING NORMAL BUSINESS HOURS? _____ _____ 6. DO YOU AGREE TO COMPLY WITH THE REGULATIONS AND THAT YOU WILL BE HELD RESPONSIBLE TO STATE AND / OR FEDERAL PESTICIDE LAWS FOR FAILURE TO OBSERVE SAID REGULATIONS? ANNUAL LICENSE FEE IS $250.00 FOR THE FISCAL YEAR JULY 1 - JUNE 30. RETURN TO: AMOUNT ENCLOSED $________________ OPERATOR IN CHARGE___________________________________________ PLEASE PRINT ARKANSAS STATE PLANT BOARD SEED DIVISION #1 NATURAL RESOURCES DRIVE LITTLE ROCK, AR 72205 SIGNATURE___________________________________________ DATE___________________________________________ ATTACHMENT FOR LISTING CHEMICALS (If extra space is needed) Or attach your own form EXAMPLE: KIND of SEED RICE SOYBEANS Kind of Treatment (List Chemical to be used Each Fungicide, Pesticide, etc.) Apron XL LS Maxim 4FS Release LC 100-799 100-758 73049-42 RATE (List ounces per hundredweight or oz per bushel) 0.0425 fluid oz per 100wt 0.16 “ “ “ “ 2.1 fl oz in 20 fl oz water per 100wt Cruiser 5FS Maxim XL Apron XL LS Apron MAXX RTA + Moly 100-941 100-916 100-799 100-945 1.28 fluid oz per 100wt 0.117 “ “ “ “ 0.48 “ “ “ “ 5.00 “ “ “ “ EPA Number Company Name & Address:__________________________________________________ Operator in Charge:_________________________________ KIND of SEED Kind of Treatment (List Chemical to be used -each Fungicide, Pesticide, etc.) EPA Number * Date:_____________ RATE (List ounces per hundredweight Or per bushel) *The EPA registration number can be found on the label of the chemical container Required Confidential Information Form Instructions: Please print clearly. This information is confidential and required by Act 1163 of 1997. The name below should appear the same as on the license application form. Last Name First Name Social Security Number - Middle Initial - Do not write below this line For Plant Board Use Only Type of License(s) Issued 9 Commercial Firm License . . . . . . . . . . . . . . . . . . 9 Commercial Individual License . . . . . . . . . . . . . . 9 2,4-D Custom Applicator Permit . . . . . . . . . . . . . 9 2,4-D OIC Authorization Permit . . . . . . . . . . . . . 9 2,4-D Pilot’s Authorization Permit . . . . . . . . . . . 9 Non-Commercial License . . . . . . . . . . . . . . . . . . 9 Tree Injector’s Permit . . . . . . . . . . . . . . . . . . . . . 9 Pesticide Dealers License . . . . . . . . . . . . . . . . . . 9 Manufacturer’s Permit . . . . . . . . . . . . . . . . . . . . . 9 Nursery Dealer License . . . . . . . . . . . . . . . . . . . . 9 Nurseryman License . . . . . . . . . . . . . . . . . . . . . . 9 Ginseng Dealer License . . . . . . . . . . . . . . . . . . . . 9 Ginseng Man License . . . . . . . . . . . . . . . . . . . . . 9 Landscape Contractors License . . . . . . . . . . . . . . 9 Pest Control License . . . . . . . . . . . . . . . . . . . . . . 9 Lime Vendors License . . . . . . . . . . . . . . . . . . . . . 9 Ag Consultants License . . . . . . . . . . . . . . . . . . . . 9 Feed Facility License . . . . . . . . . . . . . . . . . . . . . . 9 Fertilizer Facility License . . . . . . . . . . . . . . . . . . 9 Seed Labelers License . . . . . . . . . . . . . . . . . . . . . 9 Seed Treaters License . . . . . . . . . . . . . . . . . . . . . 9 Registered Seed Technologists License . . . . . . . . 9 Plant Breeders License . . . . . . . . . . . . . . . . . . . . .9 Public Grain Warehouse License . . . . . . . . . . . . . 9 Private Applicator License . . . . . . . . . . . . . . . . . . License Number ....................... ....................... ...................... ...................... ....................... ...................... ....................... ...................... ...................... ....................... ...................... ...................... ...................... ...................... ....................... ...................... ...................... ...................... ....................... ...................... ...................... ...................... ...................... ....................... ....................... During the Arkansas General Assembly legislators passed Act 1163 of 1997. This Act mandates that on and after July 1, 1997, all persons, boards, commissions, or other licensing entities issuing any occupational, professional or business license or marriage licenses will record the name, address and social security number of each person applying for such licenses on the license application, or on the license if no application is required. The Arkansas State Plant Board is required to submit this information to the Office of Child Support Enforcement.