Form 8570-17 Application for an Experimental Use Permit to Ship

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&EPA

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U.S. GOVERNMENT PRINTING OFACE: 1999- 452-584/25008

Form A

roved. 0MB No. 207()..[NEW]
OPP Identifier Number

United States

ENVIRONMENT AL PROTECTION AGENCY
Washington, DC 20460
Office of Pesticides Programs (7505C)

Application for Experimental Use Permit to Ship and
Use a Pesticide for Experimental Purposes Only

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1.Type of Application
New

D

2. Briefly explain (attach a separate sheet if necessary)
Amendment (See No. 21

Extension (Give Permit Number below)

Permit Number
3. Name and Addresa of Firm/Person to Whom the Experimental Use
Permit is to be Issued (include Zip Code) (Type or Print)

4. Name and Addreee of Shipper only if shipment is intended or if
different from applicant's name and address (include Zip Code)
(Type or Pdnt)

EPA Company Number

6. Is Product Registered with EPA?

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5. Name of Product

D

No
Yes (Give Registration Number or File Symbol below l

Registration Number ______________

File Symbol
7. Total Quantity of Product Proposed for Shipment/Use

8. Acreage or Area to be Treated

9. Proposed Period of Shipment/Use

Pounds of formulated product _________
Pounds of active ingredMlnt
10. Places from which Shipped

11. Crop/Site to be Treated

12. Specify the name and number of the contact person moat familiar
with this application.

13. Signature of Applicant or Authorized Firm Representative

14. Title

15. Date Signed

Certification
This is to certify that food or feed derived from the experimental program will not be used or offered for consumption or sale for consumption,
except by laboratory or experimental animals. if illegal residues are present in or on such food or feed.
I certify that the statements I have made on this form and all attachments thereto are true, accurate, and complete. I acknowledge that any
knowingly false or misleading statement may be punishable by fine or imprisonment, or both, under applicable law.

EPA Form 8570-17 (Rev. 1-94) Previous Editione are Obsolete

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INSTRUCTIONS

Refer to 40 CFR 172 for regulations regarding experiaental use peniits. These regulations were plblished in the FEDERAL
REGISTER on April 30, 197!> (40 FR 18780). �lete all (and only) l'Ullbered itea on the af!Plication fon1. If an EPA C�ny
NI.Jlber (Item 2) has not previously been assigned, indicate "None," and a nl.llber will be assigned on your acknowledgment copy of
the fonn. Third party applicants (those who will be testing another firm's registered product) need not COl!l>lete Item 13. on
the acknowledgment copy of this form, you will be assigned a File Nl.llber or Syni)ol for identification of this application. An
expected COl!l>letion date and the name of your EPA Contact will be entered. You may call your EPA Contact if you have not
received your permit or a letter of explanation by the date indicated.

Experimental Use Permit Data Submission

The followi� infor.1tion aust be su:aitted in triplicate and in detail (bound in removable sections A through G with
margin tabs) for all new chemicals and many new products. For some new forRLJlations, the information requested in Items C, D,
E, and F may be included by reference to other forRLJlations if adequate extrapolation may be made. 'Jhere the applicant_reque�ts
permission to test a registered product, the information requested in Items B, E, F, and G below, along with the EPA Reg1strat1on
NI.Jlber of the product, will usually suffice. R�fer to 40 CFR 158.640 t53 FR 15993, May 4, 1988] for further information.
A. A data sheet giving the chemical and physical properties of the chemica�. A COl!l>lete statement of the names and pepercentages
by weight of each Active and Inert ingredient in the forRLJlation to be shipped. This information will be handled as
condential material.
B. One copy of the proposed label including directions for use necessary for evaluation of the product. Refer to 40 CFR 172.6
for minimun labeling requirements. In certain circunstances the experimental program or other supplemental labeling may be
permissible in l;eu of full labeling. In such cases, submit a full explanation as to how the labeling will be affixed to
or acc�ny the container"
C. Toxicity data or reference to available data on the toxicity of the pesticide including, where pertinent, data on the toxic;ty
to fish and wildlife. Include a sUT111ary of this information. LD 50 values and results of eye irritation studies on the
formulated product RLJSt be included.
D. Residue data, where pertinent, on (a) food or feed coo-rnodities; (b) nonfood crops such as tobacco; and Cc) foliage or other
sites which may relate to worker hazard or adverse effects on the environment. Include a description of the analytical
method(s) used and a sUT111ary of the data.
E. Effectiveness data (required only if specified in Regulations 40 CFR 158.640, 53 FR 15993, May 4, 1988 and Registration
Guidelines 40 CFR 158.202Ci), 53 FR 15993, May 4, 1988].
F. If the pesticide is to be tested in a manner involving food or feed, and an adequate tolerance is not established to cover
the use, file a petition for a t�rary tolerance with this Agency and forward three copies with this application. If
appropriate tolerances are established already, cite applicable Regulation in Title 40 of the Code of Federal Regulations.
G. Proposed Experimental Program:
(1) Give the qualifications and the names, addresses, and telephone nl.llbers of the individuals (participants) who will
supervise the experimental work.
(2) Name the States in which the pesticide will be used and the acreage to be treated in each State. 'Jhere ffacreage" does
not apply, give extent of testing per State in more appropriate terminology. Indicate separately any other State(s) to
which the pesticide may be shipped for further distribution.
(3) Give the details of the proposed program including the types of target pests or organisms, the crops, animals, surfaces,
materials, buildings, or sites of application to be treated and the major geographical areas where the material is to be
used. For seasonal pests or crops, indicate the desired month for pesticide application to begin. Specify the use pattern,
intended plot sizes, nl.llber of plots, nuttier of replicates, dosage rates, methods of application, season of use- (spring,
surmer, fall) and timing of application (preplant, postemergence, RLJltiple (indicate pattem and nuttier), etc.).
(4) List the objectives of the proposed program including, e.g., what type(s) of data will be collected during the testing
period (performance, yield, phytotoxicity, environmental residue, etc.). Indicate your long-range testing plans, including
how many years you expect to conduct experimental testing in support of registration of this use. This information will be
helpful in evaluating the currently proposed program.
(5) Sut:mit an explanation to justify the quantity of the material requested, including various parameters used to determine
the quantity. Quantities authorized will be based on the program submitted and consideration of the types and amou,t of data
required to support registration.
(6) Propose a suitable duration for the permit coomensurate with the program. Any r�t for a period greater than 1 year
must be adequately justified.
(7) State the method of disposition of any unused material left at the conclusion of the testing program.

Paperwork Reduction Act Notice

This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. (OMB Control No. 2070-[NEW]).
Responses to this collection of information are mandatory (40 CFR 172). An agency may not conduct or sponsor, and a person is not
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recordkeeping burden for this collection of information is estimated to be 0.75 hours per response. Send comments on the Agency’s need
this formation, the accuracy of the provided burden estimates and any suggested methods for minimizing respondent burden including
through
the use of automated collection techniques to the Director, Regulatory Support Division, U.S. Environmental Protection Agency (2821T),
1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form
to this address.
(04-14-93)