ICR Attachment F - EPA Form 8500-17-N and Instructions

OMB Control Number 2070-0029; EPA ICR Number 0155.09
ICR ATTACHMENT F
“Request for Pesticide Applicator Certification in Navajo Indian Country”
EPA Form 8500-17-N and Instructions

Please read instructions before completing form.

Form Approved. OMB Control No. 2070-0029. Approval Expires xx-xx-xxxx

United States
Environmental Protection
Agency

US EPA Region IX
San Francisco, CA 94105

Request for Pesticide Applicator Certification in Navajo Indian Country
LAST NAME (+ Jr, Sr, II, III etc.)

FIRST NAME

MI

MAILING ADDRESS

CITY

STATE

ZIP
–

AREA CODE
(

TELEPHONE

COUNTY

OFFICE USE

–

)

EMAIL ADDRESS (optional)

2. BIRTH DATE:

–
M

M

–
D

D

3. FEDERAL APPLICATOR ID # (if renewal):
Y

R 9

Y

4. CERTIFICATION TYPE:

9

Initial Certificate

9

5. APPLICATOR TYPE:

9

Commercial Applicator

9

Renewal/Recertification

9

Replacement (Lost Card)

Private Applicator

6. CERTIFICATION METHOD:
a.

9 Requesting federal certificate based on valid state certificate or license. (Attach a copy of state certificate.)
State:

State Applicator Number:

Expiration Date:
M

M

-

D

D

-

Y

Y

State Applicator Category/Categories for which Certificate/License was Received (enter category code(s)):
b.

9 Self-study (ONLY for private applicators who do not hold state certification)
By signing this application below and submitting to U.S. EPA, I hereby attest to the fact that:
1. I have personally completed the EPA “Private Applicator Certification and Recertification Home Study Course Questionnaire.”
2. I understand and can apply the information therein.
3. I understand the significance of labeling and understand my legal responsibilities for the use of pesticides in accordance with label instructions and warnings;
and
4. I intend to purchase and use Restricted Use pesticides only for production of an agricultural commodity on property owned or rented by myself or my
employer or to other property if the application is made without compensation other than trading of personal services between producers of agricultural
commodities.

7. PLEASE SIGN HERE
A false statement in this certification may be grounds for denial of certification and may be punishable by fine or imprisonment (U.S. Code,
Title 18, Section 1001). I certify that all the statements that I have made on this form are true, complete and correct to the best of my
knowledge and belief, and are made in good faith.

SIGNATURE:

DATE SIGNED:

(FOR OFFICE USE:)
REC:

EPA Form 8500-17-N

APP:

INIT:

SENT:

INSTRUCTIONS FOR COMPLETING EPA FORM 8500-17-N
AND PAPERWORK REDUCTION ACT NOTICE
This form is to be used to request certification to purchase and apply Restricted Use Pesticides in
Navajo Indian Country from the U.S. Environmental Protection Agency Region IX.
1. Fill out all of the information. An email address is requested but is not required. Phone number
listed should be one at which you can be reached during business hours.
2. Enter your birth date using the numerical month-month-date-date-year-year format.
3. Enter your EPA Region 9 Federal Applicator Identification number if this is a renewal or request
for a replacement card.
4. Certificate Type: Check appropriate box. If this is your first application to Region IX for a pesticide applicator
certification in Navajo Indian Country, check “Initial Certificate”.
5. Applicator Type: Check “Private Applicator” ONLY if you will be or are applying pesticides for
production of an agricultural commodity on property owned or rented by you or your employer. All
other applicators check “Commercial Applicator”. There is no “noncommercial” or “public” federal
applicator type.
6. Certification Method: In most cases you will check “Requesting Federal Certificate based on valid
state certificate or license”.
6a. Enter the two character state for which you hold a valid certificate/license, the state applicator
number and expiration date. Enter the code for the category or categories for which you are
certified/licensed by the state using the codes listed on the back of this instruction sheet. Use the code
for the category that is an exact match to the category listed on your certificate/license. Attach a
photocopy of both sides of your state certification or license.
6b. If you do not hold a valid state applicator certificate and you are a private applicator, you may be
certified after completing the “Private Applicator Certification and Recertification Home Study
Course” and related Questionnaire.
7. Sign and date the application and mail the application with a photocopy of both sides of your state
pesticide applicator certificate/license (if you are requesting certification based on state certification),
and a passport or digital photograph of yourself to:
Federal Plan Coordinator
Pesticides Office (CED-5)
U.S. EPA Region IX
75 Hawthorne St.
San Francisco, CA 94105-3901
Paperwork Reduction Act Notice: The public reporting burden for respondents completing this
form is estimated to average about 10 minutes per response. Send comments (referencing OMB
Control Number 2070-0029 and EPA Form 8500-17-N) about the burden estimate or any other aspect
of this collection of information, including suggestions for reducing the burden to: Director,
Collection Strategies Division (2822T), U.S. Environmental Protection Agency, 1200 Pennsylvania
Ave., N.W., Washington, D.C. 20460. Do not send your completed application form to this address.

INSTRUCTIONS FOR COMPLETING FORM 8500-17-N (CONTINUED)

Codes for Applicator Categories (6a.)
Category

Code

Category

Code

Agricultural pest control

1

Aquatic pest control

5

Agricultural pest control-plant

1i

Right-of-way pest control

6

Agricultural pest control-animal

1ii

7

Forest pest control

2

Industrial, institutional, structural and health related pest
control
Public health pest control

Ornamental and turf pest control

3

Regulatory pest control

9

Seed treatment

4

Demonstration & research pest control

10

Arizona Department of Agriculture Specific Categories
Category
Code
Right-of-Way pest control - Agriculture
6a
Regulatory pest control (Government ): M-44
9a
Regulatory pest control (Government ): Rodent 9c
Fumigation – Agriculture (Private applicator)
16

Arizona Structural Pest Control specific categories
Category
Code
General & public health pest control (structural)
B1
Wood destroying insect control
B2
Weed and right of way
B3
Fumigation
B4
Turf & Ornamental
B5
Fungi inspection
B7
Wood destroying insect inspection
B8
Aquatic
B9

8

New Mexico specific categories
Category
Code
Structural pest control
7a
Vertebrate animal control
7b
Fumigation
7c
Rodenticide, private
17
Other pest control
18

Utah specific categories
Category
Aquatic-surface water
Aquatic-sewer root control
Structural & health-related pest control
Predator control/mechanical ejection
device
Predator control/protective collar
Aerial
Vertebrate Animal
Fumigation/Stored Commodities
Wood-Preservation
Wood Destroying organisms

Code
5a
5b
7d
9a
9b
11
12
13
14
15