Address
of emergency pesticide application:
Street address
City,
state, zip code
Telephone number
County
(e.g, school, private residence, daycare facility, etc.)
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Property
type
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(e.g., backyard by sandbox)
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Specific
location of application on property
Approximate area
covered by application
OFFICE USE ONLY
Date received
Method of transmission
Incident number
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PLEASE SEND COMPLETED FORM TO:
New York State Department of
Health Bureau of
Toxic Substance Assessment Attention: Emergency Notification Exemption
Staff 547 River
Street, Room 330 Troy. NY 12180-2216 Fax - (518) 402-7819
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Description o f the situation that required the
emergency application
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Amount of
product(s) applied expressed as undiluted material
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Active
ingredient(s) in product(s)
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U.S.
Environmental Protection Agency registration number(s) of product(s)
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Product name(s) of pesticide(s) applied
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