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FOR OFFICE USE ONLY OBSOLETE Main by mny89786

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									                                                                                                                                                     FOR OFFICE USE ONLY
 OBSOLETE                 Maine Board of Pesticides Control                       Maine Dept of Environmental Protection
                          28 State House Station                                  17 State House Station                                     ID#:
 PESTICIDE                Augusta, Maine 04333-0028                               Augusta, Maine 04333-0017                                  ZONE:
 INVENTORY                Tel: 207-287-2731; Fax: 207-287-7548                    Tel: 207-287-7688 or 800-452-1942                          Date Rec’d:
 FORM                     www.thinkfirstspraylast.org                             www.state.me.us/dep/home.htm                               Date Entered:
 NAME and MAILING ADDRESS:                                                                                               TELEPHONE NUMBER—REQUIRED

                                                                                                                DAYTIME:

                                                                                                                EVENING:
 PHYSICAL LOCATION OF PESTICIDES:                                                                               If you are not a year-round resident, please list
                                                                                                                name, address, and phone number(s) of a contact
                                                                                                                person:


                                                                                 Weight/Volume of
                                                                                                           TOTAL Weight/Volume              Type of
                                                 Liquid (L) or      Number of    EACH CONTAINER             (specify total amount of                            Condition of
       Pesticide Active Ingredient*                                              (specify container size                                   Container
                                                   Solid (S)        Containers                                product on hand for                                Container
                                                                                  only—not the product                                 (i.e., plastic, paper)
                                                                                                                   disposal)
                                                                                        amount)

EXAMPLE: Lead Arsenate                                 S                2                5 lbs.                    7½ lbs.                   Paper                  Good

EXAMPLE: 2,4,5-T                                       L                1              10 gals.                   4 GALS.                     Metal                 Poor




*Active ingredients are often listed on the front of the                                                                   Remember to store pesticides in a dry,
pesticide label. If the pesticide has more than one active            PLEASE RETURN COMPLETED FORM                         secure location. Store containers of liquid in
ingredient, please list them all. If the active ingredient is not       TO THE BOARD OF PESTICIDES                         hard plastic containers. Doubled plastic trash
listed, or is unreadable, please describe the product using           CONTROL AT THE ADDRESS SHOWN                         bags are recommended for paper or
the brand name, EPA registration number, or any other                             ABOVE                                    cardboard packages. DO NOT MIX
identifying information you can find on the label.                                                                         chemicals together.

Completed by: _____________________________________                     Date: ______________________________                                               Page ___ of ___
                                                            Weight/Volume of
                                                                                      TOTAL Weight/Volume              Type of
                               Liquid (L) or   Number of    EACH CONTAINER             (specify total amount of                            Condition of
Pesticide Active Ingredient*                                (specify container size                                   Container
                                 Solid (S)     Containers                                product on hand for                                Container
                                                             only—not the product                                 (i.e., plastic, paper)
                                                                                              disposal)
                                                                   amount)

								
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