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Business License Colorado

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					Log for Distribution of Restricted Use Pesticides (Colorado)
Date of delivery Information on Pesticide                               Information on licensed applicator (and authorized agent when applicable)
or pick-up       Pesticide Brand Name EPA Registration no.   Quantity   License type       Issued by      exp. Date       license # & categories applicators name   business name   address   town   state   zip code
                                                                        [ ] QS             [ ] CDA
                                                                        [ ] Private App [ ] EPA R8
                                                                        [ ] ________       [ ]______
                                                                        [ ] pesticide provided to authorized agent?                               agents name                       address   town   state   zip code
                                                                        [ ] obtained signed authorization and copy of license with categories?
                                                                        [ ] QS             [ ] CDA
                                                                        [ ] Private App [ ] EPA R8
                                                                          ________         ______
                                                                        [ ] pesticide provided to authorized agent?                              agents name                        address   town   state   zip code
                                                                        [ ] obtained signed authorization and copy of license with categories?
                                                                        [ ] QS             [ ] CDA
                                                                        [ ] Private App [ ] EPA R8
                                                                          ________         ______
                                                                        [ ] pesticide provided to authorized agent?                              agents name                        address   town   state   zip code

                                                                        [ ] obtained signed authorization and copy of license with categories?
                                                                        [ ] QS             [ ] CDA
                                                                        [ ] Private App [ ] EPA R8
                                                                          ________         ______
                                                                        [ ] pesticide provided to authorized agent?                              agents name                        address   town   state   zip code
                                                                        [ ] obtained signed authorization and copy of license with categories?
                                                                        [ ] QS             [ ] CDA
                                                                        [ ] Private App [ ] EPA R8
                                                                          ________         ______
                                                                        [ ] pesticide provided to authorized agent?                              agents name                        address   town   state   zip code
                                                                        [ ] obtained signed authorization and copy of license with categories?
                                                                        [ ] QS             [ ] CDA
                                                                        [ ] Private App [ ] EPA R8
                                                                          ________         ______
                                                                        [ ] pesticide provided to authorized agent?                              agents name                        address   town   state   zip code
                                                                        [ ] obtained signed authorization and copy of license with categories?
                                                                        [ ] QS             [ ] CDA
                                                                        [ ] Private App [ ] EPA R8
                                                                          ________         ______
                                                                        [ ] pesticide provided to authorized agent?                              agents name                        address   town   state   zip code
                                                                        [ ] obtained signed authorization and copy of license with categories?
                                                                        [ ] QS             [ ] CDA
                                                                        [ ] Private App [ ] EPA R8
                                                                          ________         ______
                                                                        [ ] pesticide provided to authorized agent?                              agents name                        address   town   state   zip code

                                                                        [ ] obtained signed authorization and copy of license with categories?
Information to be recorded by dealer for each state or federal RUP sale or distribution

Required Item                                                                            Which part of rule 13.3 this Additional comments
                                                                                         requirement comes from:

1. Name of licensed applicator                                                           13.3(a)                    Private applicator, QS, or license from other state or entity

2. Business name                                                                         13.3(a)

3. Business address of applicator - which includes:
a. Street address                                                                        13.3(a)
b. Street address 2                                                                      13.3(a)
c. City                                                                                  13.3(a)
d. State                                                                                 13.3(a)
e. Zip code                                                                              13.3(a)

4. Either applicator license info or pesticide dealer license number - which includes:   13.3(b)
a. Certification number                                                                  13.3(b)
b. Issuing entity                                                                        13.3(b)
c. Expiration date                                                                       13.3(b)
d. Appropriate categories of certification                                               13.3(b)
or:
e. Pesticide dealer license number                                                       13.3(b)

5. Product information - which includes                                                  13.3(c)                    provide sufficient information to determine total amount in
                                                                                                                    pounds (dry products) or gallons (liquids) of product
a. Pesticide Product name                                                                                           date of delivery of pick-up, not date of sale or order.
b. EPA registration number
c. Colorado SLN #, if applicable
d. Quantity                                                                              13.3(d)
e. Number
f. Unit (e.g.. Pounds or gallons)
g. Date of distribution                                                                  13.3(e)

6. Was provided to agent of licensed applicator? If Yes then record the following:       13.3(f)                    Y or N. If yes, complete items below
a. Name of authorized agent                                                              (f)(1)
b. Street address                                                                        (f)(1)
c. Street address 2                                                                      (f)(1)
d. City                                                                                  (f)(1)
e. State                                                                                 (f)(1)
f. Zip code                                                                              (f)(1)

7. Obtain a record of applicator's license showing categories of licensure               (f)(2)                     for example, have a photocopy on file, including the category
                                                                                                                    information. (on back of CDA license cards)
yes/no                                                                                   (f)(2)

8. Obtain and keep on file a signed authorization from licensed applicator               (f)(3)                     So the agent doesn't need to bring authorization every time

yes/no




61b03148-6899-420e-a3a8-d4f9b16595f7.xls List of required information 7/16/2010

				
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Description: Business License Colorado document sample