Application for Coverage under the General Permit for Invasive Weed Control

Application for Coverage under the General Permit for Invasive Weed Control
Organization/Agency*
Contact Person*

First NameLast Name
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Pesticide Applicator Name*
Pesticide Applicator Certification Numbers*
Treatment area*
Target species (select to confirm)*

Project is intended to control invasive weed species with a rank of 30 or higher on the AKEPIC website
AKEPIC website
Project management (select to confirm)*

Project is overseen or managed by a state agency (including Soil and Water Conservation Districts by definition)
Treatment site characteristics (select to confirm)*

Pesticides wil be applied only to dry land that is a minimum of 20 feet from the edge of any surface water (except for wiper/injection applications, which may be done up to water's edge)
Endangered species (select to confirm)*

Treatment site has not been identified as habitat for threatened or endangered species referenced in 50 CFR 17.11-17.12
Pesticide products (check all that apply)*

1. AquaMaster/Roundup Custom for Aquatic and Terrestrial use, 524-3432. Cornerstone 5 Plus, 1381-2413. Escort XP Herbicide, 432-15494. EZ-Ject Diamondback Herbicide Shells, 83220-15. Garlon 4 Ultra, 62719-5276. Habitat, 241-426-676907. Horsepower Selective Herbicide, 228-3138. Milestone, 62719-5199. Telar XP Herbicide, 352-65410. Transline, 62719-259
I certify under penalty of perjury, that all of the information and exhibits in this application are true, accurate, and complete.*

Yes, all of the information and exhibits in this application are true, accurate, and complete
Signature*

Clear
Date*

MonthDayYear
Date
Applicant's Title*
All applications must be signed by a duly authorized employee of the state, borough, or city agency.
Please verify that you are human*
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