Post Pesticide Application Data Submission Form

Within 48 hours, following completion of treatment, please provide a copy of your pesticide application data using this form.

Before submitting this form, please ensure that the information is correct. Submit one form for each application.

Please note, this data will be included in summary form in the City’s IPM Policy C501A Annual report and will be publically available.

City of Edmonton Project Information

Application Notification Reference #

City of Edmonton Contract Manager, Project Manager, or City of Edmonton Senior Landscape Specialist for Private Development Email:

Only @edmonton.ca addresses.

City of Edmonton Contract Number or Servicing Agreement:

City of Edmonton Project Name and where applicable Neighbourhood/ Stage:

Contractor / Applicator Information

Contractor Name:

Certified Applicator Name:

Certified Applicator Licence Number:

Certified Applicator Licence Expiry Date:

Name of Representative Completing Form:

Representative's Phone Number:

Representative's Email Address:

Application Information

Treatment Site Address or Legal Land Description:

Size of Treatment Area:

Date

Pest Control Information

Pest to be Controlled and Host Plant if applicable:

Pesticide Name:

PCP Number:

Total Concentrate Product(s) Used (to Label Instruction):

Where label instructions include dilution, report only the amount of concentrate used.

Units:

FOIP Statement

This personal information is being collected under the authority of section 33(c) of the Freedom of Information and Protection of Privacy (FOIP) Act. The City of Edmonton will use this information for purposes necessary to and consistent with administering the Contractor’s Environmental Responsibility Package, implementation of the Integrated Pest Management Policy C501A, and administration of the Pesticide Exemption Program. Personal information in the custody or under the control of the City is protected in accordance with the privacy provisions of FOIP. If you have any questions regarding the collection or use of this information, please contact the Melissa Brown, Environmental Manager, 9th Floor, 10111 104 Ave NW, Edmonton, AB T5J 0J4, 780-292-1132.

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Post Pesticide Application Data Submission Form

Post Pesticide Application Data Submission Form

Contact Us

Melissa Brown

Title	Environmental Manager
Email	ipm@edmonton.ca