Researcher: Certification #: Mailing Address: Phone: Fax: e-mail: Today’s Date: Intended Disposition of Crop Product EPA Active Federal If yes, EUP# & Intended Estimated Estimated Crop Tolerance/ Location of Name Reg. # Ingredient(s) EUP? Company Crop/Site/Target Number of Amount of Destruct Exemption Application [Yes/No] Name Pest Acres Active [Yes/No] & Reference* Ingredient Intended Used Method
Researcher: Certification #: Mailing Address: Phone: Fax: e-mail: Today’s Date: Intended Disposition of Crop Product Name EPA Reg. # Active Ingredient(s) Federal EUP? [Yes/No] If yes, EUP# & Company Name Intended Crop/Site/Target Pest Estimated Number of Acres Estimated Amount of Active Ingredient Used Crop Destruct [Yes/No] & Intended Method Tolerance/ Exemption Reference* Location of Application
EUPform_SPRrev11.12_2.docx