United
Sates
FORM
APPROVED
Environmental
Protection
Agency
OMB
NO.
2070­
0078
Washington,
DC
20460
Pesticide
Report
for
Pesticide­
Producing
and
Device­
Producing
Establishments
Section
7,
Federal
Insecticide,
Fungicide,
and
Rodenticide
Act,
(
7
U.
S.
C.
136e)

Note:
Read
all
instructions
before
completing.
Production
and
distribution/
sales
volumes
information
reported
on
this
form
is
treated
as
business
confidential.

1.
Mailing
Address
8.
EPA
Est.
No.

9.
Establishment
Name
2.
City
3.
State
or
Country
4.
Zip
Code
10.
Site
Address
5.
Name
of
Establishment
Officer
6.
Title
7.
Date
(
Mo.,
Day,
Year)
11.
City
12.
State
or
Country
13.
Zip
Code
14.
Telephone
Number
16.

15.
Signature
of
Establishment
Officer
PESTICIDE
PRODUCTION
INFORMATION
17.
Product
Code
(
If
"
4"
and
chemical,
attatch
formulation
per
instructions.
If
"
4"
and
Device,
go
to
Item
19)
18.
EPA
Product
Registration
Number
19.
Product
Name
20.
Product
Classification
21.
Product
Type
22.
Market
Sold
To
23.
Use
Classification
24.
Unit
of
measure:
P=
Pound
G=
Gallons
K=
Kilograms
L=
Liters
T=
Tons
U=
Units
25.
Amount
Produced,
Repackaged
or
Relabeled
Last
Year
26.
Amount
Sold
or
Distributed
Last
Year
­
US
27.
Amount
Sold
or
Distributed
Last
Year
­
Foreign
28.
Amount
To
Be
Produced,
Repackaged,
Relabeled
This
Year
17.
Product
Code
(
If
"
4"
and
chemical,
attatch
formulation
per
instructions.
If
"
4"
and
Device,
go
to
Item
19)
18.
EPA
Product
Registration
Number
19.
Product
Name
20.
Product
Classification
21.
Product
Type
22.
Market
Sold
To
23.
Use
Classification
24.
Unit
of
measure:
P=
Pound
G=
Gallons
K=
Kilograms
L=
Liters
T=
Tons
U=
Units
25.
Amount
Produced,
Repackaged
or
Relabeled
Last
Year
26.
Amount
Sold
or
Distributed
Last
Year
­
US
27.
Amount
Sold
or
Distributed
Last
Year
­
Foreign
28.
Amount
To
Be
Produced,
Repackaged,
Relabeled
This
Year
17.
Product
Code
(
If
"
4"
and
chemical,
attatch
formulation
per
instructions.
If
"
4"
and
Device,
go
to
Item
19)
18.
EPA
Product
Registration
Number
19.
Product
Name
20.
Product
Classification
21.
Product
Type
22.
Market
Sold
To
23.
Use
Classification
24.
Unit
of
measure:
P=
Pound
G=
Gallons
K=
Kilograms
L=
Liters
T=
Tons
U=
Units
25.
Amount
Produced,
Repackaged,
or
Relabeled
Last
Year
26.
Amount
Sold
or
Distributed
Last
Year
­
US
27.
Amount
Sold
or
Distributed
Last
Year
­
Foreign
28.
Amount
To
Be
Produced,
Repackaged,
Relabeled
This
Year
CONTINUED
ON
ATTACHED
SHEET
(
)
THIS
IS
PAGE
____
OF
_____

EPA
Reviewer
EPA
Office
Postmark
Date
or
Report
Received
Date
Date
Reviewed
29.
Reporting
Year
2001
EPA
Form
3540­
16
(
Rev.
08­
01)
Previous
editions
are
obsolete.
