### 1 INSTRUCTIONS FOR COMPLETING EPA FORM 7100

- 0 1

PAPERWORK REDUCTION ACT NOTICE

This form is to be used to request certification to purchase and apply Restricted Use Pesticides in Indian Country from the U.S. Environmental Protection Agency.

1. Fill out all of the information. An email address is requested but is not required. Phone number listed should be one at which you can be reached during business hours. The address should be your business address, if applicable, for commercial appl icators since this information will be posted to EPA's website

.

2. Enter your birth date using the numerical month

- month

- date

- date

- year

- year format.

3. Enter your EPA Federal Applicator Identification number if this is a renewal or request for a replacement card.

4. Certificate Type: Check appropriate box. If this is your first application for a pesticide applicator certification in Indian Country, check “Initial Certificate”. If contact information submitted on a previous

form is erroneous or outdated, please use the “Replacement (Lost Card)” option.

5. Applicator Type: Check “Private Applicator” ONLY if you will be or are applying pesticides for production of an agricultural commodity on property owned or rented by you or your employer . All other applicators check “Commercial Applicator”. There is no “noncommercial” or “public” federal applicator

type.

6. Certification Method: In most cases you will check “ Requesting federal certificate based on valid federal, state or tribal certificate or license”.

6a. Enter the two character state for which you hold a valid certificate/license, if applicable, the applicator number for your existing certificate, and expir ation date. Enter the code for the category or categories for which you are currently certified/licensed. A ttach a photocopy of both sides of your current and valid federal, state or tribal certification or license

. T he underlying c ertificate needs to co me from a state or

tribe that shares a contiguous boundary with the area of Indian country in which you intend to apply

RUPs.

6b. If you do not hold a valid federal, state or tribal applicator certificate and you are a pplying to be a private applicator, y ou may be certified after submitting documentation of completion of the on

- line training course provided by EPA. However, in the interim while EPA is developing the course, private applicators can pursue this option by submitting documentation of completi on of coursework or training that covers the general standards of competency outlined in 40 CFR 171.5 and 40 CFR 171.6. These standards include practical knowledge of pest problems and pest control practices associated with agricultural operations; proper storage, use, handling and disposal of the pesticides and containers; related legal responsibility; and practical knowledge of Federal supervisory requirements, including labeling, regarding the application of restricted use pesticides by noncertified app licators. Courses that cover the material outlined in 40 CFR 171.4(b) are also appropriate because they overlap with the material described in 40 CFR 171.5 and 40 CFR 171.6. For those taking the state training in the interim, EPA expects that this training will take an applicator at least 8 to 16 hours to adequately attain the knowledge necessary to apply restricted use pesticides. All courses used for this certification must be state

- approved

from states that have Administrator

- approved certification plan s, or otherwise approved by the Administrator. Training must be completed within the two years prior to certification. A false statement

### 2 in this certification, including regarding the completion of training, may be grounds for denial of

certification and may be punishable by fine or imprisonment (U.S. Code, Title 18, Section 1001).



### If you have questions about what courses are applicable, please contact the appropriate Regional office (see addresses on page 3). To determine the appropriate Regional office, see http://www.epa.gov/epahome/whereyoulive.htm

. Include documentation of completion of the required training course(s)

.

To apply for recertification, complete one of the options described above during the 12 months preceding the expiration of your current certificate.

7. Sign and date the application and mail the application with a photocopy of both sides of your existing federal, state, or tribal pesticide applicator certificate/license (if you are requesting certification based on a federal, s tate, or tribal certification) t o the appropriate Regional office (see addresses on page s 2 and 3 ). To determine the appropriate Regional office, see http://www.epa.gov/epahome/whereyoulive.htm

Paperwork Reduction Act Notice: The public reporting burden for respondents complet ing this form is estimated to average about 10 minutes per response. Send comments (ref erencing OMB Control Number

2070

- 0029 and EPA Form 7100

- 01 ) about the burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden to: Director, Collection Strategies Division (2822T), U.S. Environmental Protection Agency, 1200 Pennsylvania Ave., N.W., Washington, D.C. 20460. Do not send your completed application form to this address.

Privacy Act Statement: Title 7 United States Code, section 136i(a)(1) authorizes the collection of this

information. The primary use of this informatio n is to identify persons certified by EPA under the Agency’s federal certification plan which administers and oversees certification of applicators of restricted use pesticides. Disclosures of this information may be made pursuant to published routine use s, including to appropriate agencies for law enforcement purposes and to an EPA website for information purposes. Providing the requested information is voluntary, but failing to do so may result in EPA’s inability to approve your request to become, or ma intain your status as, a certified applicator of restricted use pesticides. For a full description of this system notice, including routine uses, see EPA

- 59 [ 77 FR 2060; January 12, 2012 ].

### 3 Addresses for Submitting Form Region Address

1 Federal Plan Coordinator

Toxics and Pesticide Unit Pesticides Program (OES05

- 4)

U.S. EPA

- New England, Region 1 5 Post Office Sq, Suite 100 Boston, MA 02109

- 3912

2 U.S. Environmental Protection Agency, Region 2

Pesticides Team Attn: Pesticide Certification Training Coordinator 2890 Woodbridge Avenue

MS

- 500 Edison, New Jersey 08837

3 No Federally Recognized Tribes

4 Federal Tribal Plan Coordinator USEPA Region 4

- Pesticides Section 61 Forsyth Street SW

SNAFC

- 12th Floor Atlanta, GA 30303

5 U.S. EPA Land and Chemicals Division, CMB

77 W. Jackson Blvd. LC

- 8J Chicago, IL 60604

6 U.S. Environmental Protection Agency 1445 Ross Avenue, Suite 1200 Pesticides Section (6PD

- P) Dallas, Texas 75202

- 2722

7 Pesticide Applicator Ce rtification Coordinator U.S. Environmental Protection Agency

- Region 7

WWPD/TOPE/PEST

901 N. 5th St Kansas City, KS 66101

8 US EPA, Region 8

Attn: Region 8 Certification 1595 Wynkoop St, 8P

- P3T Denver, CO 80202

9 

### Federal Plan Coordinator Pesticides Office (CED

- 5) U.S. EPA Region IX

75 Hawthorne St. San Francisco, CA 94105

- 3901

10 Federal Pesticide Applicator Certification Program

Pesticides & Toxics Unit US EPA, Region 10 1200 Sixth Ave, Ste. 900, OCE

- 084 Seattle, WA 98101