Pesticide Use Notification Form

Completing this step will confirm if your planned application falls within a Pesticide Exemption area. Before submitting this form, please ensure that the information is correct, and submit one form for each application. The intended area and planned pesticide application will be publicly available. This information will be forwarded to your City of Edmonton Contract or Project Manager, who will provide confirmation for the planned application to proceed.

Before proceeding with the application, you must wait for acceptance of your intended application from your City of Edmonton Project or Contract Manager.

If you have not heard back within 72 hours (excluding weekends and holidays) of submitting your notification contact your City of Edmonton Contract or Project Manager directly.

City of Edmonton Project Information

City of Edmonton Contract Manager, Project Manager, or City of Edmonton Senior Landscape Specialist for Private Development name:

City of Edmonton Contract Manager, Project Manager, or City of Edmonton Senior Landscape Specialist for Private Development email:

Only @edmonton.ca addresses.

City of Edmonton Contract Number or City of Edmonton Servicing Agreement:

City of Edmonton Project Name and where applicable Neighbourhood / Stage:

Contractor / Applicator Information

Contractor Name:

Certified Applicator Name:

Certified Applicator Licence Number:

Certified Applicator Licence Expiry Date:

Name of Representative Completing Form:

Representative's Phone Number:

Representative's Email Address:

Treatment Information

Treatment Site Address or Legal Land Description:

Size of Treatment Area:

Application Planned for the Week of

Pest Information

Pest to be Controlled/Host tree/Plant if Applicable:

Pesticide Name:

PCP Number:

Application Equipment:

FOIP Statement

This personal information is being collected under the authority of section 33(c) of the Freedom of Information and Protection of Privacy (FOIP) Act. The City of Edmonton will use this information for purposes necessary to and consistent with administering the Contractor’s Environmental Responsibility Package, implementation of the Integrated Pest Management Policy C501A, and administration of the Pesticide Exemption Program. Personal information in the custody or under the control of the City is protected in accordance with the privacy provisions of FOIP. If you have any questions regarding the collection or use of this information, please contact the Melissa Brown, Environmental Manager, 9th Floor, 10111 104 Ave NW, Edmonton, AB T5J 0J4, 780-292-1132.

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Pesticide Use Notification Form

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Melissa Brown