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<br />. :d2~j!~~~~~*~\\ <br /> <br />ii-I,.. ~~L+, <br />\\tll~~ ~"..t ~ ", l <br />\~-;\,' ~~ -:.'!t ,;...~ <br />\<~<.~ ,".' ~o <br />0"".. . ,,'" <br />. '., ."'OR1'" <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 />:3ERMISSION IS REQUESTED TO CONTRACT FOR AERIAL APPLICATION OF PESTICIDE <br /> <br />NAME OF CITY <br /> <br />TO SPRAY FOR CONTROL OF <br /> <br />REQUEST DATE <br /> <br /> <br />o SG..W10 (~ <br />TITLE <br /> <br />TELEPHONE # <br /> <br />NAME OF CITY OFFICIAL <br /> <br />Sc..o bN <br />NAME OF CITY OFFICIACc.ot-lI~(...\") <br /> <br /> <br />JR- <br /> <br />,0(- '-11-6'730 <br /> <br />TITLE <br /> <br />TELEPHONE # <br /> <br />A-N(q~ L.Pr -e, L\ ~\ <br /> <br />VE:c-ru <br /> <br />c...o t...JTR.o l.- D \ lZ.. ~ L'\'b <br /> <br />,0 I ; 2.. C) ~ ; 2. ~4 4 <br /> <br />Il,ERIAL APPLICATOR SERVICE INFORMATION: <br />NAME OF APPLICATOR SERVICE <br /> <br />NAME OF PilOT <br /> <br />TELEPHONE # <br /> <br /> <br />SICK 5 <br /> <br /> <br />1> '2- ~ \--.J SoL. u.. tv\ <br /> <br />:) 1<6 ; 4S'v ; (p4J-~ <br />STATE/ZIP CODE <br /> <br />MAILING ADDRESS <br /> <br />CITY <br /> <br />I S-O <br /> <br /> <br />+f~t..&J~l> <br /> <br />Ht-J 6{,r'i<?' <br /> <br />:3ESTICIOE INFORMATION <br />CHEMICAL NAME <br /> <br />PF?I<-M 13- rn~ J..J <br /> <br />~O-f'''O <br /> <br />RATE OF APPLICATION <br /> <br />(00-=1- 1b5/~L- <br /> <br />DATE OF APPLICATION <br /> <br />% CONCENTRATION <br /> <br />METHOD [UlV, SPRAYER, OTHER (SPECIFY)] <br /> <br />METHOD PUBLIC NOTICE <br /> <br />DATE OF PUBLIC NOTICE <br /> <br /> <br />SIGNATURE OF CITY OFFICIAL <br /> <br />SUBMIT YOUR APPLICATION TO: (Please fill in city address below) <br /> <br />APPROVED BY <br /> <br />Department of Health <br />Division of Air Quality <br />918 E Divide, 2nd Floor <br />Bismarck, NO 58501-1947 <br />Telephone: 701-328-5188 <br /> <br />Signatu,re <br /> <br />Date <br /> <br />Il,pproval 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 betol e <br />3pproval will be granted. Aircraft spraying and loading equipment must be dedicated for the use of Qnh' those chemical pesticides approved for residential U l V spraYing anc <br />10 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 />The aerial applicator must also be registered by the State of North Dakota Aeronautics Commission (701-328-9650) and must have Federal Aviation Administration \ FAA) <br />3pproval 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 />1801 - 23'd Ave, North. Room 211, Fargo, NO, 58502, 701-232-8949. <br /> <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 pestIcide <br />3pplicator. <br /> <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 />