Pesticide Application Permit

PESTICIDE APPLICATION PERMIT

Permit Number:    Issue Date:    Expiration Date:

RECITALS

WHEREAS, Issuing Authority: has the statutory authority to regulate pesticide applications within its jurisdiction and to issue permits subject to conditions designed to protect human health and the environment; and

WHEREAS, Applicant Name: seeks authorization to apply the pesticide(s) described below at the Property Location described in this permit and represents that Applicant will comply with all applicable statutes, regulations, label directions, and permit conditions; and

WHEREAS, Issuing Authority and Applicant agree that issuance of this permit is conditioned upon Applicant's compliance with the terms, mitigation measures, and certifications set forth herein;

APPLICANT INFORMATION

PROPERTY AND SITE INFORMATION

Parcel / Lot Identifier:    Latitude:    Longitude:

PESTICIDE DETAILS

Active Ingredient(s):    Formulation / Concentration:

Target Pest(s):

Ground spray    Aerial application    Bait stations    Trunk injection    Other:

Application Rate:    Area to be Treated:

SCOPE OF WORK

CONDITIONS, NOTIFICATIONS, AND SAFEGUARDS

Application Dates Authorized: From to . Any deviation requires prior written approval of Issuing Authority.

Mandatory Buffer Zones (feet): . Applicant shall maintain buffers from surface water, wells, and sensitive habitats as required by label and permit conditions.

Notice Provided:    Date of Notice:    Method:

INSURANCE, INDEMNITY, AND CERTIFICATIONS

Certificate of Insurance on file:    Policy Limits:

Applicant hereby agrees to indemnify and hold harmless Issuing Authority and its officers, employees and agents from any claims, damages or liability arising out of Applicant's performance under this permit, except to the extent caused by Issuing Authority's gross negligence or willful misconduct.

PAYMENT TERMS

Late Fee: . Failure to pay fees when due authorizes Issuing Authority to suspend or revoke this permit after notice.

TERM AND TERMINATION

Permit Term Commencement Date: . Term Expiration Date: .

Either party may terminate this permit for cause upon days' written notice specifying the grounds for termination. Issuing Authority may suspend or revoke the permit immediately if applicant's actions present an imminent threat to human health or the environment.

CONFIDENTIALITY

All information provided by Applicant that is designated in writing as confidential shall be maintained in confidence by Issuing Authority to the extent permitted by law. Notwithstanding the foregoing, Applicant acknowledges that records relating to permit issuance, monitoring, and enforcement may be subject to disclosure under applicable public records laws and such disclosures are not breaches of this confidentiality provision.

GOVERNING LAW

This permit and any dispute arising out of it shall be governed by the laws of the State of without regard to its choice-of-law rules.

ENTIRE AGREEMENT

This permit constitutes the entire agreement between Issuing Authority and Applicant with respect to the subject matter herein and supersedes all prior written or oral agreements, representations, and understandings. No amendment to this permit shall be effective unless made in writing and signed by both parties.

REPRESENTATIONS AND CERTIFICATION

By signing below, Applicant certifies under penalty of perjury that Applicant and any applicators performing work under this permit are properly licensed and certified, will apply pesticides in strict compliance with the product label, applicable laws and regulations, and the terms of this permit. Applicant acknowledges that incorrect or incomplete information may result in suspension or revocation of the permit and may subject Applicant to enforcement action.

Operator / Applicator Name:    License / Certification Number:

Emergency Contact Name and Phone:

ADDITIONAL CONDITIONS

Applicant acknowledges receipt of the Special Conditions and agrees to comply:

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