Form 3540-16 Pesticide Reports for Pesticide-Producing and Device-Pro

OMB Control No. 2070-0078
Expires on mm/dd/yyyy

United States

ENVIRONMENTAL PROTECTION AGENCY

Washington, DC 20460
Pesticide Report for Pesticide-Producing and Device-Producing Establishments
Office of Enforcement and Compliance Assurance
Section 7, Federal Insecticide, Fungicide, and Rodenticide Act (7 U.S.C. sec. 136e)
http://www.epa.gov/compliance/pesticide-establishment-registration-and-reporting

1. Establishment
Name

--

2. EPA Est. No.

--

3. Establishment Site Address
4. City

5 State

6. Province/Region

7. Country

8. Zip/Postal Code

9. Establishment Mailing Address
10. City

11. State

12. Province/Region

13. Country

15. Telephone Number

14. Zip/Postal Code

16. Email

17. Check if your establishment's name or address
changed

Yes

18. Did you produce or distribute in 2022?

No

19. Company Name
20. Company Site Address
21. City

22. State

23. Province/Region

24 Country

25. Zip/Postal Code

26. Company Mailing Address
27. City

28. State

29. Province/Region

30. Country

32. Telephone Number

31. Zip/Postal Code

33. Email

35. Check if your Authorized Agent changed

34. Check if your company name or address changed
36. Name of Company Official
or Authorized Agent

37. Title of Company Official
or Authorized Agent

38. Signature of Company Official or
Authorized Agent (Original signature required)

39. Date

40. Telephone Number of Company
Official or Authorized Agent
EPA Reviewer

EPA Office

41. Email Of Company Official
or Authorized Agent
Post Mark Date

Date Entered

Comments

Clear Form

EPA Form 3540-16 (Rev. 12/2022) Previous versions are obsolete.

Print

Reporting Year 2022
Page ____ of ____

OMB Control No. 2070-0078
Expires on mm/dd/yyyy

United States

ENVIRONMENTAL PROTECTION AGENCY

Washington, DC 20460
Pesticide Report for Pesticide-Producing and Device-Producing Establishments
Office of Enforcement and Compliance Assurance
Section 7, Federal Insecticide, Fungicide, and Rodenticide Act (7 U.S.C. sec. 136e)
http://www.epa.gov/compliance/pesticide-establishment-registration-and-reporting

Establishment Name

EPA Est. No.

--

--

Pesticide Production Information
42. Product Code

(If "6," attach formulation per instructions.)

43. EPA Product Registration No.

44. Product Name
46. Product Type

45. Product Classification
47. Market Sold To

48. RUP Status

49. Unit of Measurement

50. Amount Produced, Repackaged or Relabeled

[2022]

51. Amount Sold or Distributed - U.S.

[2022]

52. Amount Sold or Distributed - Foreign (Foreign establishments enter "0")

[2022]

53. Amount To Be Produced, Repackaged or Relabeled in

[2023]

42. Product Code

(If "6," attach formulation per instructions.)

43. EPA Product Registration No.

44. Product Name
46. Product Type

45. Product Classification
47. Market Sold To

48. RUP Status

49. Unit of Measurement

50. Amount Produced, Repackaged or Relabeled

[2022]

51. Amount Sold or Distributed - U.S.

[2022]

52. Amount Sold or Distributed - Foreign (Foreign establishments enter "0")

[2022]

53. Amount To Be Produced, Repackaged or Relabeled in

[2023]

42. Product Code

(If "6," attach formulation per instructions.)

43. EPA Product Registration No.

44. Product Name
46. Product Type

45. Product Classification
47. Market Sold To

48. RUP Status

49. Unit of Measurement

50. Amount Produced, Repackaged or Relabeled

[2022]

51. Amount Sold or Distributed - U.S.

[2022]

52. Amount Sold or Distributed - Foreign (Foreign establishments enter "0")

[2022]

53. Amount To Be Produced, Repackaged or Relabeled in

[2023]

42. Product Code

(If "6," attach formulation per instructions.)

43. EPA Product Registration No.

44. Product Name
46. Product Type

45. Product Classification
47. Market Sold To

48. RUP Status

49. Unit of Measurement

50. Amount Produced, Repackaged or Relabeled

[2022]

51. Amount Sold or Distributed - U.S.

[2022]

52. Amount Sold or Distributed - Foreign (Foreign establishments enter "0")

[2022]

53. Amount To Be Produced, Repackaged or Relabeled in

[2023]

EPA Form 3540-16 (Rev. 12/2022) Previous versions are obsolete.

Clear Form

Print

Page ____ of _____