Attachment A-06 Form 8570-25

Form Approved 0MB Control No 2070-NEW Expiration xx/xx/xxxx

United Statea �vironmental Protection Agency
Office of Pesticide Programs. Registration Division (75O5C)
Washington. DC 20460

&EPA

Registration No. Assigned

Application for/Notification of State Registration
of a Pesticide To Meet a Special Local Need

Date Registration laaued

(Pursuant to section 24(c) of the Federal Insecticide,
Funnicide and Rodenticide Act as Amended/
2. Product is (Check onel

1. Name and Address of Applicant for Registration

□
□

4. Product Name
6. Type of Registration (Give details in Item 13 or on a separate
page, property identified and attached to this forml:
•· To pennlt UM of • new produci.
b. To .nend IPA NQia1111doM: for - Of more of 1M followlna �:
111 To pennit UM on eddldonat c:=topa o, ...,_.,

121 To "'""'' iae et addl1'on!M ....

131 To permit .,.. •� adcldonal

For State Uae Only

14) To permit.,.. of adi:lt:lonal applloadon � o, equipn,.nt.

EPA Company Number

5. tt this is a food/feed use. a tolerance or other residue clearance ia
required. Cite appropriate regulations in 40 CFR Pan 180. 185. and/or
186.
7. Nature of SP4tcial Local N..d (check one)
Thweltino,..OCW.pra,dugt;,.....,_bot'EPAforsucta ....

0

□
□

TIMN;., no El"A ••;iulwi4d ..-lldcla pcoduot whif;h...... tM concldoM of 1- within
1ha Sr.ea. would ia.- •'- .w1,1o, • ,afflcac6ow for sUClh UM within 1M term. tWld
conclllone of EPA
All eppropriaca EPA-Niti.-.d ,.ncide produc:l bl not.,,...,.._

,...._don.

□
□
□- □- □- □- □ .........
□
□ .......- D
No

9. Hae an EPA Registnidon or Experimental UH Permit for this ctMmical ever been

(I) Other (1peclfy baowl

10. Has FIFRA section 241c) registra�on for this U8e of th•
product ever. by another State, been (check appropriate
box(eal. if knownl:

If eny of tt.. .tlov• •e c:=hlcked. il•t Stll_. In ilem 13 below.

Certification
I certify that th• statemenh: I have made on thla fonn and al attachment.
thereto are true, accurate, and complete. I acknowledge that any
lcnowinaly f■IH or mlaleadlng statement may be punishable by fine or
imprisonment or both under applicable law.
Signature of Applicant or Authorized Representative

New (not EPA-registered)
Attach EPA Fonn 8570--4. Con....,.. Statarnent of
Fonn• for - ... '
3. Active lngredient(s) in Product

Y• (� In ham 13 below)

(II To ,-mit me et cln.r.nt appicadon ..-.

No AFRA MCOOil 24(cl Anon

EPA Registration Number

8. tf this regietration is an amendment to an EPA-regiatered product, ia it
for a "new use "' N defined in 40 CFR 152.3 7

peatS.

□-· □·- □ o.- □ ..□

EPA-Regiater9d

!check applcable boxlee), tr known):

Na Pf..ioul Pwml1: Acllon

kp,erimentllt u.. Pwmlt

11. Endanaarecl Species Act: tm- details In Item 13 or on • Hparat• page,
pt0pe,ty klendfled and attached to thi9 fonn)

ldantffy tha countfH where tin JM•tldde wll be used, tf Statewide, Indicate '"al.·
Provkle a ht of Federally protected endanvaredlthreatened speclH which occur in
the aNas of propoeed �e.
12. Indicate use statu• of Special Local Need. I.e.• planned dates of

use:

From:

mm/dd/yyyy

To:

mm/dd/yyyy

13. Comments (attach additional eheet. if needed)

Title
Telephone Number

I

Dato
Determination by State Agency

Thia reglatredon la for a Special Local Need and le being iHued In accordance with ...:11on 24(c) of FIFRA, u amended. To the be•t of our
knowledge, the lnformadan above la conect, eJteept ff noted In "Commenta" below or In ■ttachmentll,

Name, Title, and AddreH of State Agency Official

Comments (by State Agency Onlyl

Received by EPA

Title
Telephone Number
EPA Form 8570-25 (Rev.5-12)

I

Date

EPA COPY

I

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 152. An agency may not
conduct or sponsor, an a person is not required to respond to, a collection of information unless it displays a currently
valid OMB control number. The public reporting and record keeping burden for this collection of information is estimated
2.5 hours per response. Send comments on the Agency’s need for this information, the accuracy of the provided burden
estimates and any suggested methods for minimizing respondent burden to the Regulatory Support Division Director,
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.

·u.s. GPO: 1999-452-529125004