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<br /> <br />APPLICATION FOR AERIAL APPLICATION FOR PESTICIDE OVER A CITY <br />North Dakota Department of Health <br />Division of Air Quality <br />, SFN 14493 (12.05) <br /> <br />'ERMISSION IS REQUESTED TO CONTRACT FOR AERIAL APPLICATION OF PESTICIDE- <br /> <br />NAME Of CITY TO SPRAY FOR CONTROL OF REQUEST DATE <br />NAME OF CITY OFFICIAL TITLE TELEPHONE # <br />NAME OF CITY OFFICIAL TITLE TELEPHONE # <br /> <br />\ERIAL APPLICATOR SERVICE INfORMATION: <br />NAME OF APPLICATOR SERVICE <br /> <br />NAME Of PILOT <br /> <br />TELEPHONE # <br /> <br />Airborne Custom Spraying Inc. <br /> <br />Dean R. Solum License #20034981 <br /> <br />(218)456-2465 <br /> <br />1507 Coumy Highway 21 <br /> <br />CITY <br />Ha Istad <br /> <br />STATElZIP CODE <br />Minnesota 56548-9420 <br /> <br />MAILING ADDRESS <br /> <br />'ESTICIDE INFORMATION: <br /> <br />CHEMICAL NAME - Permex 30+30 <br />EPA# 655-81 I <br />300/0 Concen\rntion <br /> <br />Permex 31 +66 <br />EPA# 655-812 <br />31 % Com:entratio[] <br /> <br />% CONCENTRATION <br /> <br />RATE OF APPLICATION <br /> <br />.007 Ibs <br /> <br />METHOD IULV. SPRAYER, OTHER (SPECIFY)) <br /> <br />DATE Of APPLICATION <br />BETWEEN 05101106 & 10/01/08 <br /> <br />UL V, AERIAL <br />METHOD PUBLIC NOTICE - CIRCLE WHICHEVER PERTAINS TO YOUR CITY. <br /> <br />RADIO, TELEVlSION, TELEPHONE, OR POSTED NOTICE <br /> <br />DATE OF PUBLIC NOTICE <br /> <br />24HRS IN ADVANCE OF <br />APPLICATION <br /> <br />SIGNATURE OF CITY OFFICIAL <br /> <br /> <br />. .' <br /> <br />SUBMIT YOUR APPLICATION TO: (Please fill in city address below) <br /> <br />APPROVED BY <br /> <br />Departmenl or Health <br />Division of AIr Quality <br />91B E DMde. 2nd Floor <br />Bismarck, ND 58501.1947 <br />Telephone: 701-326-51 B8 <br /> <br />Signature <br /> <br />Date <br /> <br />ppraval from the Department of Health is requIred for aenal spra1fi"9 of pesticides over a city [NDAC 33-15-1 0-01]. This application form must be completed before <br />pprova\ will be granted. Aircraft spraying and loading equipment must be dedicated for the use or Q!!\Y. those che~lcal pesticIdes approved for residential ULV spraying an <br />o other chemical pesticides will be used In the spraying or loading equipment. If a public health emergency exists; these requirements may be waived. <br /> <br />he aerial applicator must also be registered by the State of North Dakota Aeronautics Commission (701-328-9650) and must haye Federal Aviation Administration (FAA) <br />pproval to conduct a spraying operation over a city congested area. To receive this approval the aerial application can contact the FAA Flight Standards District Office. <br />BOl - 23" Ave, North. Room 21 I. Fargo. ND. 58502. 701 .232.8949. - <br /> <br />he North Dakota Department of Health will not be held nable-for any accidents, misapplications, errors in mixing, etc, These are the sole responsibility or the pesticide <br />pplicator. . <br /> <br />. the application of pesticide Is not completed within five days of the date proposed, please contact this office. An extension may be granted. <br />