Iowa Admin. Code r. 21-45.28
The department shall issue a temporary certificate to private applicators for a single purchase/single use of restricted pesticides in situations declared to be an emergency by the department, upon receipt of the following Cornpleted and signed affidavit.
21-45.28(206) EMERGENCY USE OF A RESTRICTED USE PESTICIDE BY A PRIVATE APPLICATOR
Emergency Single Purchase/Single Use of Restricted Pesticide-Affidavit. The Label which I have read, indicates:
Brand name of pesticide:_____________________________________________________________
Federal Registration Number:_________________________________________________________
Name of Active Ingredient(s):_________________________________________________________
Percentage of Active Ingredient(s):_____________________________________________________
If the pesticide product is to be mixed with a carrier, show the amount of pesticide product per gallon of tank mix:
Application rate per acre:_____________________________________________________________
Name pest to be controlled:___________________________________________________________
At what stage of development is the pest most easily controlled:
State degree of hazard (signal word):___________________________________________________
Describe safety equipment required:____________________________________________________
What is the reCornmended antidote for this product:_______________________________________
List environmental precaution shown on label:___________________________________________
Length of time until re-entry, if given:__________________________________________________
Preharvest interval days required:______________________________________________________
Describe method of container disposal:__________________________________________________
I wish to make application of this pesticide on (date)__________________________________________ and I hereby swear under penalty of perjury that I understand the above label information and warnings.
_________________________
(name of private applicator)
This rule is intended to implement Iowa Code sections 206.4 and 206.5.
Iowa Admin. Code r. 21-45.28