Pre-registration form
Waste Pesticide Disposal Program

Name
Company
Phone Number
Mailing Address

Name of Product
Manufacture
Active Ingredient
USDA or EPA Reg. No.
Approx. Amount
Liquid Dry
Container Size and Type
Container Condition or Approximate Age
Name of Product
Manufacture
Active Ingredient
USDA or EPA Reg. No.
Approx. Amount
Liquid Dry
Container Size and Type
Container Condition or Approximate Age

Print form and mail to:

Tim Hagen
South Dakota Department of Agriculture, Regulatory Services
Foss Building--523 East Capitol
Pierre, SD 57501-3182
1-800-228-5254