OBSERVATIONS and QUANTITY
PESTICIDE CONTAMINANT
CONTAMINATED EQUIPMENT FORM
comment on reverse
1
Store Name
2
Owner (if different
from owner of store)
5
Commercial Name
if the name of the pesticide that contaminated the equipment is known
6
Active Ingredient name
if the AI of the pesticide that contaminated the equipment is known
8
Manufacturer's name
and address
if the name of the manufacturer of the pesticide that contaminated the equipment is
known
9
Formulator's name and
address
if the name of the formulator of the pesticide that contaminated the equipment is known
13
UN Chemical Hazards
Classification
(warning diamonds on
the containers)
14
How supplied / Name
of Supplier
18
Level of contamination
19
Physical form
23
Size of equipment
24
Unit of Measure of the
size of equipment
27
Quantity
(only complete one of
27a or 27b)
use 1 & 2 to indicate primary and secondary hazards or write the hazards as a comment
not shown on label
Central Government
Extension service
Name of supplier
purchase
Farmer purchase
Donation (indicate
Unknown
donor in comments
Other (specify)
section)
surface
saturated
impregnated
other (specify)
sprayer (portable)
Tools
sprayer (vehicular)
other (specify)
enter the size of the equipment as a number of units in number 24
Metre
Cubic Metre
Square Metre
Either 27a
When
equipment
can be
counted
other (specify)
Number of
pieces of
equipment
Or 27b
When equipment cannot be counted estimate the dimensions of the pile
Length (m)
Width (m)
Height (m)
28
Photo of label
File name
Description
29
Photo of equipment
Photo of
contamination
File name
Description
File name
Description
30
Version 1.04 1 11 2005
Question
Number
Detailed Comment