Private applicator pesticide record keeping form for the worker protection standard and State and Federally restricted use pesticides.	AGRI-450 4-10-02
Records Required	Application #	Application#	Application#	Application#	Application#	Application#	Application#
Date (mm/dd/yy),,
Field or Site ID (1,2,3)
County, Distance, Direction from the Nearest Town (2)
Acres/Size or Number Treated (1,2)
Crop/Commodity (1,2)
Complete Product Name (1,2,3)
Active Ingredient(s) (3)
EPA Registration Number (1,2,3)
Total Amount Used (1)
Restricted Entry Interval (REI) (3)
Time of Application (2,3)
Air Temperature (2)
Wind Speed and Direction (2)
Type of Equipment Used, “N” Number for Aircraft (2)
Name of Applicator (1,2)
Pesticide License Number of Applicator (1)
Signature of Owner of Crop/Commodity (2)
Address of Owner of Crop/commodity (2)

Required for Federally Restricted Use Pesticides. These records must be kept for two (2) years.

Required for State Restricted Use Pesticides. These records must be kept for two (2) years.

Required for ALL PESTICIDED (insecticides, herbicides, fungicides, etc.) under the provisions of the Worker Protection Standard. These records must be kept for thirty (30) days after the end of the restricted entry interval 9REI) for the respective pesticide. Exception: Agricultural owners in family farm situations are NOT required to record this information for themselves or members of their immediate family. But the information must be recorded if any employee is from outside the immediate family.

This form was developed by Ples Spradley, Cooperative Extension Service, University of Arkansas, and Reviewed by the Arkansas State Plant Board, October, 1996.