Please read instructions before completing form. Form Approved. OMB Control No. 2070-0029. Approval Expires 02-28-2015

United States

Environmental Protection

Agency 

## US EPA Region IX

San Francisco, CA 94105

Request for Pesticide Applicator Certification in Navajo Indian Country

LAST NAME (+ Jr, Sr, II, III etc.) FIRST NAME MI

MAILING ADDRESS

CITY STATE ZIP + 4

–

AREA CODE TELEPHONE COUNTY OFFICE USE

()

–

EMAIL ADDRESS (optional)

2. BIRTH DATE: 3. FEDERAL APPLICATOR ID # (if renewal): R 9

4. CERTIFICATION TYPE: 

### 9 Initial Certificate 

### 9 Renewal/Recertification 

### 9 Replacement (Lost Card)

5. APPLICATOR TYPE: 

### 9 Commercial Applicator 

### 9 Private Applicator

6. CERTIFICATION METHOD:

a. 

### 9 Requesting federal certificate based on valid state certific ate or license. (Attach a copy of state certificate.)

State: State Applicator Number:

Expiration Date:

State Applicator Category/Categories for which Certif icate/License was Received (enter category code(s)):

b. 

### 9 Self-study (ONLY for private applicators who do not hold state certification)

By signing this application below and submitting to U.S. EPA, I hereby attest to the fact that:

1. I have personally completed the EPA “Private Applicator Certif ication and Recertification Ho me Study Course Questionnair e.”

2. I understand and can appl y the information therein.

3. I understand the significance of labeling and understand my legal responsibilities for the use of pesticides in accordan ce with label instructions and warnings;

and

4. I intend to purchase and use Restricted Use pesticides only for production of an agricul tural commodity on property owne d or rented by myself or my

employer or to other pr operty if the application is made without compensati on other than trading of personal services between p roducers of agricultural

commodities.

7. PLEASE SIGN HERE

A false statement in this certification may be grounds for deni al of certification and may be punishable by fine or imprisonmen t (U.S. Code,

Title 18, Section 1001). I certify that all the statements that I have made on this form are true, complete and correct to the best of my

knowledge and belief, and are made in good faith.

SIGNATURE: DATE SIGNED:

(FOR OFFICE USE:)

REC: APP: INIT: SENT:

EPA Form 8500-17-N**INS T**  **RU CTI**  **ONS F**  **OR COM**  **P L**  **E T**  **ING E**  **P A F**  **ORM 8500­**  **17­ N** 

**AN D P**  **A P**  **E RWORK**  **REDU CT**  **IO N AC**  **T NO**  **T ICE** 

T h i s f o r m i s to b e use d to r e q u e st c e r ti f i c a ti on to pur c ha se a n d a ppl y R e st r i c t e d U s e P e st i c ide s in

**Na v**  **a j**  **o I**  **n d**  **ian Co**  **u n**  **t r**  **y** f r om t he U

. S

. En v i r onm e nta l P r o te c t i on Age n c y R e g ion I X.

1. F i l l o ut a l l o f the i nf o r m a ti on

. An e m a i l a dd r e ss i s r e q u e st e d but i s n o t r e q u i r e d

. P h one n u m b e r

l i st e d sho u ld b e one a t w hi c h yo u c a n be r e a c he d d ur ing busi ne ss ho ur s.

2. En te r yo ur bi r th d a te usi ng the n u m e r ica l m on th

­ m o n t h

­ d a te

­ d a t e

­ ye a r

­ ye a r f o r m a t.

3. En te r y o ur EP A R e gi on 9 F e de r a l A pp l ica to r I de n ti f ica ti on n u m b e r i f thi s i s a r e ne w a l o r r e q u e st

f o r a r e pl a c e m e nt c a r d

.

4. C e r ti f ica te T y p e : C he c k a ppr o pr i a te bo x. I f th i s i s your f i r s t appl i c a ti on to R e gio n I X f o r a pe st i c ide a ppl ica to r

c e r ti f ica ti on i n Na v a jo I ndi a n C o u n tr y

, c he c k “ I ni ti a l C e r ti f i c a t e ”

.

5. A ppli c a to r T y pe : C he c k “ P r i v a te A pp li c a to r ” ON LY if yo u wil l b e o r a r e a ppl y ing p e st i c ide s f o r

pr o d uc t ion o f a n a g r i c u l tur a l c om m odi t y on pr o p e r ty owne d o r r e n t e d by yo u o r y o ur e m ploye r

. Al l

o t he r a ppl i c a to r s c he c k “ C om m e r c i a l A ppli c a to r ”

. T he r e i s no “ no nc om m e r c i a l ” o r “ publ i c ” f e de r a l

a ppl i c a to r ty p e

.

6. C e r ti f i c a ti on Me t hod: I n m o st c a se s yo u w il l c he c k “ R e q u e st ing F e de r a l C e r ti f ica te ba se d on v a l id

st a te c e r ti f i c a t e o r l i c e ns e ”

.

6a

. En te r the two c h a r a c te r a bb r e vi a ti on f o r the st a te in whi c h yo u h old a v a l id c e r ti f i c a t e /l i c e n s e

, the

st a te a ppl i c a to r n u m b e r

, a n d the e xp i r a ti on d a t e

. En t e r t he c ode f o r the c a tego r y o r c a teg o r ies f o r

whi c h yo u a r e c e r ti f ied / li c e n s e d b y the st a te usi n g t he c ode s li st e d on the ba c k o f thi s in st r uc ti on

she e t. U s e the c ode f o r the c a tego r y th a t i s a n e xa c t m a tch to the c a tego r y li st e d on yo ur

c e r ti f ica te / l ic e n s e

. **At t**  **a c**  **h a**  **p h**  **ot oc**  **op y**  **o f**  **b ot**  **h s**  **i d**  **e s**  **of yo**  **u r**  **st a**  **t e**  **c e**  **r t**  **ifi c**  **a t**  **i o**  **n or**  **li c**  **e n**  **se**

.

6b. I f y o u do no t hold a v a l id st a te a ppl i c a to r c e r ti f i c a te a n d yo u a r e a pr i v a te a ppl i c a to r

, y o u m a y b e

c e r ti f ied a f t e r c om p le t ing the “ P r i v a te A pp li c a to r C e r ti f i c a ti on a n d R e c e r ti f i c a ti on H om e S tudy

C o ur se ” a nd r e l a ted Qu e st ionn a i r e

.

7. S i g n a nd d a t e the a ppl ica ti on a nd m a il the a ppl ica ti on wi t h a ph o toc o p y o f bo t h si de s o f yo ur st a te

pe st i c ide a ppl i c a to r c e r ti f ica te / l ic e n s e ( i f yo u a r e r e q u e st i ng c e r ti f i c a ti on ba se d on st a te c e r ti f ica ti on)

,

a n d a pa s spo r t o r d igi ta l pho tog r a ph o f y o ur s e l f to:

F e de r a l P l a n C o o r din a to r

P e st i c ide s Of f i c e ( C ED

­ 5 )

U

. S

. E P A R e gi on I X

75 Ha w th o r ne S t.

S a n F r a n c i sc o

, C A 94105­ 3901

**Pa p**  **e r**  **wor k**  **R e**  **d u**  **c t**  **i o**  **n Ac**  **t Not**  **i c**  **e :**  T h e publi c r e p o r ti ng bur de n f o r r e sponde n ts c om p le t in g t h i s

f o r m i s e st im a t e d to a ve r a ge a bo ut 10 m i n ut e s p e r r e spon s e

. S e nd c omm e nts ( r e f e r e n c ing OMB

C o n tr ol Nu m b e r 2070­ 0029 a n d EP A F o r m 8500­ 17­ N ) a bo ut th e bur de n e st im a t e o r a n y o t he r a spe c t

o f thi s c o ll e c ti on of in f o r m a ti o n

, in c l u din g su g ge st ion s f o r r e d u c ing the bur de n to: Di r e c t o r

, C o ll e c ti on S tra te gie s Divi s i on ( 2822T )

, U

. S

. En v i r onm e n ta l P r o tec ti on Age nc y

, 1200 P e nn syl v a ni a

Ave

. , N.W.

, W a sh ing ton

, D.C

. 20460

. Do no t se nd your c om ple t e d a ppli c a ti on f o r m to thi s a d d r e ss.**INS T**  **RU CTI**  **ONS F**  **OR COM**  **P L**  **E T**  **ING F**  **ORM 850**  **0­ 17­**  **N (CONTINUED)**



### Co **d es**  **f o**  **r A**  **p p**  **lic a**  **t o**  **r Cat**  **e g**  **o r**  **ies (**  **6a**

**. )** 

C a t e g o ry C o d e C a t e g o ry C o d e

Ag ri cu l t u ra l Pe s t C o n t ro l 1 Aq u a t i c Pe s t C o n t ro l 5

Ag ri cu l t u ra l Pe s t C o n t ro l ­P l a n t 1 i R i g h t ­o f

­ W a y Pe s t C o n t ro l 6

Ag ri cu l t u ra l Pe s t C o n t ro l ­An i m a l 1 i i I n d u s t ri a l

, I n s t i t u t i o n a l

, S t ru ct u ra l a n d H e a l t h R e l a t e d P e s t

C o n t ro l 7

F o re s t Pe s t C o n t ro l 2 Pu b l i c H e a l t h Pe s t C o n t ro l 8

O rn a m e n t a l a n d T u r f Pe s t C o n t ro l 3 R e g u l a t o ry Pe s t C o n t ro l 9

Se e d T re a t m e n t 4 D e m o n s t ra t i o n & R e s e a rch Pe s t C o n t ro l 1 0

**A r**  **i zo**  **n a**  **D e**  **p a**  **r tm**  **e n**  **t o**  **f A**  **g r**  **i c**  **u l**  **t u**  **r e**  **S p**  **e c**  **i fi**  **c C**  **a te**  **g o**  **r i**  **e s** 

C a t e g o ry C o d e

R i g h t ­o f

­ W a y p e s t co n t ro l

­ Ag r i cu l t u re 6 a

R e g u l a t o ry p e s t co n t ro l ( G o v e rn m e n t ) : M­4 4 9 a

R e g u l a t o ry p e s t co n t ro l ( G o v e rn m e n t ) : R o d e n t 9 c

F u m i g a t i o n

– Ag r i cu l t u re (Pr i v a t e a p p l i ca t o r) 1 6

**A r**  **i zo**  **n a**  **Str u**  **c t**  **u r**  **a l**  **Pe s**  **t C**  **o n**  **tr o**  **l s**  **p e**  **c i**  **fi c**  **c a**  **te g**  **o r**  **i e**  **s**

**C a**  **te g**  **o r**  **y C**  **o d**  **e**

G e n e ra l Pe s t & Pu b l i c H e a l t h B1

C o n t ro l o f W o o d D e s t ro y i n g I n s e ct s B2

R i g h t o f W a y a n d W e e d C o n t ro l B3

F u m i g a t i o n B4

T u r f & O rn a m e n t a l H o rt i cu l t u re B5

F u n g i I n s p e ct i o n B7

W o o d D e s t ro yi n g I n s e ct I n s p e ct i o n B8

Aq u a t i c Pe s t C o n t ro l B9 **U ta**  **h s**  **p e**  **c i**  **f i**  **c c**  **a te**  **g o**  **r i**  **e s** 

**C a**  **te g**  **o r**  **y C**  **o d**  **e**

Aq u a t i c­Su r f a ce W a t e r 5 a

Aq u a t i c­Se w e r R o o t C o n t ro l 5 b

St ru ct u ra l & H e a l t h ­R e l a t e d 7

R e g u l a t o ry 9

Ae ri a l Ap p l i ca t i o n 1 1

Ve rt e b ra t e An i m a l 1 2

F u m i g a t i o n / St o re d C o mm o d i t i e s 1 3

W o o d

­ Pre s e r v a t i o n 1 4

W o o d D e s t ro yi n g O rg a n i s m s 1 5