For Inspector Use Only Name of Product (as listed on label) Use (circle all that apply) Manufacturer Name/Address/Phone # (Do not list distributor or sales person) Reason for Use (ex: fertility, pest control, etc.) Listed on your Active and Allowed list? (attached) For IDALS Use Only Used On site Discontinued Used Plan to use Want reviewed Y N Allowed Restricted ________ Prohibited Not reviewed Used On site Discontinued Used Plan to use Want reviewed Y N Allowed Restricted ________ Prohibited Not reviewed Used On site Discontinued Used Plan to use Want reviewed Y N Allowed Restricted ________ Prohibited Not reviewed Used On site Discontinued Used Plan to use Want reviewed Y N Allowed Restricted ________ Prohibited Not reviewed Used On site Discontinued Used Plan to use Want reviewed Y N Allowed Restricted ________ Prohibited Not reviewed Used On site Discontinued Used Plan to use Want reviewed Y N Allowed Restricted ________ Prohibited Not reviewed Used On site Discontinued Used Plan to use Want reviewed Y N Allowed Restricted ________ Prohibited Not reviewed Used On site Discontinued Used Plan to use Want reviewed Y N Allowed Restricted ________ Prohibited Not reviewed Used On site Discontinued Used Plan to use Want reviewed Y N Allowed Restricted ________ Prohibited Not reviewed Used On site Discontinued Used Plan to use Want reviewed Y N Allowed Restricted ________ Prohibited Not reviewed
For Inspector Use Only Name of Product (as listed on label) Use (circle all that apply) Manufacturer Name/Address/Phone # (Do not list distributor or sales person) Reason for Use (ex: fertility, pest control, etc.) Listed on your Active and Allowed list? (attached) For IDALS Use Only Used On site Discontinued Used Plan to use Want reviewed Y N Allowed Restricted ________ Prohibited Not reviewed Used On site Discontinued Used Plan to use Want reviewed Y N Allowed Restricted ________ Prohibited Not reviewed Used On site Discontinued Used Plan to use Want reviewed Y N Allowed Restricted ________ Prohibited Not reviewed Used On site Discontinued Used Plan to use Want reviewed Y N Allowed Restricted ________ Prohibited Not reviewed Used On site Discontinued Used Plan to use Want reviewed Y N Allowed Restricted ________ Prohibited Not reviewed Used On site Discontinued Used Plan to use Want reviewed Y N Allowed Restricted ________ Prohibited Not reviewed Used On site Discontinued Used Plan to use Want reviewed Y N Allowed Restricted ________ Prohibited Not reviewed Used On site Discontinued Used Plan to use Want reviewed Y N Allowed Restricted ________ Prohibited Not reviewed Used On site Discontinued Used Plan to use Want reviewed Y N Allowed Restricted ________ Prohibited Not reviewed Used On site Discontinued Used Plan to use Want reviewed Y N Allowed Restricted ________ Prohibited Not reviewed
For Inspector Use Only Name of Product (as listed on label) Use (circle all that apply) Manufacturer Name/Address/Phone # (Do not list distributor or sales person) Reason for Use (ex: fertility, pest control, etc.) Listed on your Active and Allowed list? (attached) For IDALS Use Only Used On site Discontinued Used Plan to use Want reviewed Y N Allowed Restricted ________ Prohibited Not reviewed Used On site Discontinued Used Plan to use Want reviewed Y N Allowed Restricted ________ Prohibited Not reviewed Used On site Discontinued Used Plan to use Want reviewed Y N Allowed Restricted ________ Prohibited Not reviewed Used On site Discontinued Used Plan to use Want reviewed Y N Allowed Restricted ________ Prohibited Not reviewed Used On site Discontinued Used Plan to use Want reviewed Y N Allowed Restricted ________ Prohibited Not reviewed Used On site Discontinued Used Plan to use Want reviewed Y N Allowed Restricted ________ Prohibited Not reviewed Used On site Discontinued Used Plan to use Want reviewed Y N Allowed Restricted ________ Prohibited Not reviewed Used On site Discontinued Used Plan to use Want reviewed Y N Allowed Restricted ________ Prohibited Not reviewed Used On site Discontinued Used Plan to use Want reviewed Y N Allowed Restricted ________ Prohibited Not reviewed Used On site Discontinued Used Plan to use Want reviewed Y N Allowed Restricted ________ Prohibited Not reviewed