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<br /> <br />APPlICATION FOR AERIAL APPUCATlON FOR PESTICIDE OVER A CITY <br />North Dakota Depadlnent of He&Ilh <br />Division of NrQually <br />SFN 1448lJ ps.ao) <br /> <br />PERMISSION IS REQUESTED TO CONTRACr FOR AERlALAPPUCA11DN OF PESI1CIOE: <br /> <br />NAME OF CITY TO SPRAY FOR OONTRCIL OF REQUEST DATE <br />NAME OF CITY OFFICIAL TITLE TElEPHOtE . <br />NAME OF CITY OFFICIAL TITLE TELEPHONE . <br /> .' <br /> <br />AERIAL APPUCATOR SERVICE INFORMATION: <br />NAME OF APPUCATOR SERVICE <br />Fhrbo<V\e. C\JS\O"^,, S ("c,\; ','1\ '1:1'\(..- <br />MAlUHG ADDRESS <br />\~1 0 }-\. ~WAJ a\ <br /> <br />NMEOFPILOT TB.EPHONE II <br />Oe~ ;<. SO \U'h\ L \c.e.'i"\Se*"l,'i1ifI" ~''6 4'5(.,-;)'-\ <t,5 <br /> <br /> <br />arv <br />1-\ ~-6-\~ <br /> <br />STATEIZIP CODE <br />f{\n~~SL\~. '1'/dD <br /> <br />PESTICIDE INFORMATION: <br /> <br />CHEMlCAL NAME - %CONCENTRAlION RATE OF APPLICATION <br />\S'fA ~ '6 ~ ~q - 4 :l EfJA4 "'3~- \\ c,\,o "",,A~ 4~;;\-\~35 <br />6\o,",,,,':.-\- ?7(), ?cUl.". qe-ciV\~1\Q..,\~;;\ 't(,t,. ~~"'_*"N\e. '30-t30 ~O .00-' \bs. <br />METHOD (ULV. SPRAYER. OTHER (SPEaFY)) DATE OF APPUCATION <br />L)Lv' , Ae.r~ ~\ bC!t'u:.tcv\ <br /> '5 -\ -05 10 -\ -05'" <br />METHOD PU8UC NOTICE DATE OF PUBUC NOTICE <br /> <br />I <br /> <br />I-TUI1E OF CITY 0FFl<>AL <br /> <br />I-ClFatYCFRCIM. <br /> <br />SUSMfT YOUR APPlJCATION TO: (PIee8e. In clly...... below) <br />Department of HeeIIh <br />DIvisIon of Nr QuaIIly <br />Box S520 <br />Bismarck, ND 58!i06-552O <br />Telephone: 701-32&6188 <br /> <br />APPROVED BY <br /> <br />~..... <br /> <br />Dale <br /> <br />ApptovaI from the D8pe1tment of HeaIIh Is required for aedal SIJIIIYing of p8lIII:Ide5 over a cIly [NDAC a3-15-10-01}. ThIs applIcaIion roan must be completed before <br />appRMII will be gnriBd. AiRlIaIltpnlJingand faedngeqcjpm8nlmustbe dIldIcaI8d blte..-of glhoeec:hemk:8lpeslicldea appIOV8d tor midenIiaIlLV spraying <br />and no oIher d1emIc:aI pesIIddes .. be U88d in 11e..... eM' kI8IIng oquipment. If a pdIIIc he8IIh __gllI1I:y tlIIilIIs.lIese ~ may be waived. <br />Theaerilllllpfllicab.lI'MIStalsObe~byIheSlal8ofNodbOllllcalllA8Rln8tllicsCommfsslon (701-328-9E15O) and must have FedeaalAvlatIonAdlrinl8lr8lion (FAA) <br />applOV8I toconcluct a spraying opendIan over._con.! I' II.... To I8C8Ive 1hIs appIOVIII1he8llll8l ~cancont8Ct the FAA FIght Sf8ndaIds DIsIrict 0IIce. <br />1801 - ~ Ave. Nodh. Room 211, FajJo. NO, 585Crl. 70143N949. <br />The NortI DekoIa DeparIment of HeaIIh wit not be held IaIlIe tar." acddenIs. ~iaiaeI.lIc8IioIlS. enors in milling. efC. TMse are the sole RlSpOIIIltIrlIiIy of lie peslIcIde <br />appIc:ator. <br />U the appllcallon of pesllclde Is not completed within ftve d8ya of .... def8 pt"OpOIled. please contact this offJce. An extension may be granted. <br />