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sAT S <br /> '..i::;11:1;::::,:•::4‘... APPLICATION FOR AERIAL APPLICATION FOR PESTICIDE OVER A CITY <br /> e: ^ F': North Dakota Department of Health <br /> '� Division of Air Quality <br /> ''' . ` y SFN 14493(9-09) <br /> ° NOR <br /> PERMISSION IS REQUESTED TO CONTRACT FOR AERIAL APPLICATION OF PESTICIDE: <br /> NAME OF CITY TO SPRAY FOR CONTROL OF REQUEST DATE <br /> Cass County Vector Control Mosquitoes <br /> NAME OF CITY CONTACT TITLE TELEPHONE # <br /> 5111 1--2-P(H6P-- 911Z-CZ'itIz --7bi -2/ C3._2n49 <br /> MAILING ADDRESS CITY STATE/ZIP CODE <br /> 1201 Main Ave W West Fargo ND, 58078-1301 <br /> E-MAIL ADDRESS <br /> 1-2.-N.111 CR FD @ ( ASS, C oo Wi-J NO ,.(7o) <br /> AERIAL APPLICATOR SERVICE INFORMATION: <br /> NAME OF APPLICATOR SERVICE NAME OF PILOT TELEPHONE# <br /> Airborne Custom Spraying, Inc. Dean Solum 218-456-2465 <br /> MAILING ADDRESS CITY STATE/ZIP CODE <br /> 1507 County Highway 21 Halstad MN, 56548 <br /> PESTICIDE INFORMATION: <br /> CHEMICAL NAME Either or-Trumpet EC#5481-4811/Dibrom#54814802 %CONCENTRATION RATE OF APPLICATION <br /> Evoluer 30-30#769-9833/Kontrol 30-30#73748-53/Foray 48B#73049-4274 781/87.42/303/12.654 1 oz1/.75 oz2/.37 oz3/32 oz4 <br /> METHOD[ULV,SPRAYER, OTHER(SPECIFY)] DATE OF APPLICATION <br /> Aerial - ULV { Between 5/1/13&10/31/13 <br /> � <br /> METHOD PUBLIC NOTICE(check all that apply) Radio L�FNewspaper *I Television ,Website DATE OF PUBLIC NOTICE <br /> ❑Posted Notification ❑Telephone ❑Other(Specify)111 48 hrs before application <br /> SIGNATURE OF CITY CONTACT <br /> SUBMIT YOUR APPLICATION TO: TO BE COMPLETED BY THE NORTH DAKOTA DEPARTMENT OF HEALTH <br /> North Dakota Department of Health APPROVAL BY <br /> Division of Air Quality <br /> 918 E Divide,2nd Floor <br /> Bismarck,ND 58501-1947 Signature: <br /> Fax Number:701-328-5185 <br /> Telephone: 701-328-5188 <br /> Date: <br /> Approval from the Department of Health is required for aerial spraying of pesticides over a city[NDAC 33-15-10-01]. This application form must be completed before <br /> approval will be granted. Aircraft spraying and loading equipment must be dedicated for the use of only those chemical pesticides approved for residential ULV <br /> spraying and no other chemical pesticides will be used in the spraying or loading equipment. If a public health emergency exists,these requirements may be waived. <br /> The aerial applicator must also be registered by the State of North Dakota Aeronautics Commission(701-328-9650)and must have Federal Aviation Administration <br /> (FAA)approval to conduct a spraying operation over a city congested area. To receive this approval the aerial application can contact the FAA Flight Standards <br /> District Office,1801-23"Ave. North,Room 211, Fargo,ND,58502,701-232-8949. <br /> The North Dakota Department of Health will not be held liable for any accidents,misapplications,errors in mixing,etc. These are the sole responsibility of the <br /> pesticide applicator. <br /> If the application of pesticide is not completed within five days of the date proposed,please contact this office. An extension may be granted. <br />