The Arkansas DP-42 form is an application used to request permission for the delivery of bulk pesticides to a dealer's facility, as well as for the dealer to dispense these pesticides. This form ensures compliance with state regulations and establishes guidelines for safe handling and labeling of pesticides. To begin the process, fill out the form by clicking the button below.
The Arkansas DP-42 form is a critical document for those involved in the distribution of bulk pesticides within the state. This application serves as a formal request for permission to deliver bulk pesticides to a dealer's facility and to allow the dealer to dispense these products to licensed applicators. The form requires detailed information, including the dealer's name, address, and contact details, as well as the manufacturer's information. Additionally, it outlines specific conditions that must be met for approval, such as ensuring all products are registered with the State Plant Board and that containers are clearly marked with safety warnings. The form also mandates that containers be labeled accurately and equipped with sampling points for regulatory compliance. Dealers must adhere to EPA guidelines and DOT regulations to prevent contamination and ensure safe handling. Furthermore, if the dealer is not the manufacturer's agent, a resident agent must be designated for service of process. The DP-42 form is essential for maintaining the integrity and safety of pesticide distribution in Arkansas, and any changes post-approval require a formal amendment to the application.
Form DP-42
ARKANSAS STATE PLANT BOARD
(Rev 09/08)
DIVISION OF PESTICIDES
P. O. BOX 1069, LITTLE ROCK, ARKANSAS 72203
APPLICATION FOR PERMISSION TO DELIVER BULK PESTICIDES
TO A DEALER’S FACILITY AND PERMISSION FOR THE DEALER
TO DISPENSE BULK PESTICIDES
IN STR UC TIO N S:
Complete and submit to the Arkansas State Plant Board. A signed copy will be returned upon approval to each
location.
EPA ESTABLISHMENT NUMBER. _______________________________
________________________________________________________________________________________
Dealer’s Name
____________________________________________________________(______)_____________________
Complete Mailing AddressTelephone Number
CityStateZip Code
Manufacturer’s or Registrant’s Name
_____________________________________________________________(______)____________________
________________________________________________________________________________________.
City
State
Zip Code
The above manufacturer requests permission to deliver bulk pesticides and the above dealer request permission to install facilities for dispensing the pesticide to Arkansas licensed applicators at certain locations, as are hereinafter designated, subject to the following conditions:
1.All products will be registered with the State Plant Board by the manufacturer.
2.All containers to be dispensed from will be plainly marked by the dealer with paint or stenciling in large letters showing the name and address of the dealer applicant, and a phrase similar to “Warning --
Contains Pesticides.”
3.All containers will bear a complete label, as registered, for the product therein, including the manufacturer’s name and address as provided by the manufacturer.
4.All containers must contain suitable sample points to permit sampling by personnel of the State Plant Board. Samples must be accepted without reservation as being representative of the material therein and described on the label attached.
5.All containers are charged or recharged, the filling inlet will be sealed by the dealer in such a manner as to prevent tampering with the contents.
6.The dealer must meet EPA established guidelines for handling bulk pesticides and in accordance with all Department of Transportation (DOT) regulations.
7.The dealer must make adequate provision for handling to prevent contamination or injury to persons, livestock, and crops.
8.The dealer and person in charge as indicated herein will be responsible for overall operation of the location.
DP-42 page 2
9.In those cases in which the dealer is not the manufacturer’s agent, the manufacturer shall designate a resident agent for service of process.
10.Containers, prior to being used for a different pesticide, will be thoroughly cleaned by the dealer and relabeled.
11.All metering devices will be subject to approval of the Weights and Measures Division of the Plant Board.
BULK HANDLING LOCATION -- The location, product(s), the applicator(s) to be serviced by the dealer, manufacturer’s resident agent, and the person in charge of the dealer’s operation will be as follows:
Location (be specific)
Products (List complete brand name.)
Container 1 ______________________________________ Size _______ Gals. EPA Reg. No. ____________
Container 2 ______________________________________ Size _______ Gals. EPA Reg. No. ____________
Container 3 ______________________________________ Size _______ Gals. EPA Reg. No. ____________
Applicator (s)
__________________________________________________________________________________________
Manufacturer’s Resident Agent ________________________________________________________________
Address
Dealer ____________________________________________________________________________________
Person in Charge ___________________________________________________________________________
Address ________________________________________________Phone No. ________________________
NOTE: If changes are desired after approval, an amendment to this application must be filed.
DO NOT WRITE IN THIS SPACE
APPROVED FOR 20 ______
_________________________________
PESTICIDE DIVISION
_______________________________
DATE
PERMIT NUMBER
Dealer______________________________________
Title _______________________________________
Date _______________________________________
Signature ___________________________________
Manufacturer ________________________________
Signature____________________________________
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