As required under Section 73(3)(a) and 85(3)(a) of Regulation 63/09 made under the Pesticides Act. The licensed aerial exterminator is responsible for completing this document and the accuracy if it's contents. These records must be kept for two years following the date of pesticide application.
For Ministry Use Only Client Number
Aerial Application Permit Number (if required) Crop/Target Site Pest Pesticide PCP Number
Name (for multiple clients use back of form) Address
Type Model Registration Marks (Aeronautical Act)
Tank or Hopper Capacity (in Litre or kg) Date of Last Calibration (mm/yyyy)
am pm
Pesticide Used (product name)
Hour Minute
Location to be treated*
Rate kg/hectare Size of Treated Area (hectare) Quantity (in Litre or kg)
Direction Altitude
Wind Direction Wind Speed Temperature Relative Humidity
*Location to be treated should match the location to be treated indicated in the permit issued.
Operator Name Operator Licence Number Comments (use reverse side if necessary) Use reverse side to describe incidents that happened out of the normal course of operations Exterminator Name Exterminator Licence Number
Signature Date (yyyy/mm/dd)
Date (yyyy/mm/dd) Time Location Reported To Reported By Details, Contacts Follow up required etc.