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Kern County Department of Agriculture and Measurement Standards

County of Kern
Agriculture and Measurement Standards
Forms
Stack of Paper
Forms and Documents
All available forms and documents are arranged by Division and, except where noted, stored in Adobe pdf format. View pdf documents with Adobe Acrobat Reader. If your document is not listed please call (661)868-6300 or e-mail the Division Deputy to request a copy.

CONSUMER and AGRICULTURAL PROTECTION

Forms and Documents

Contact Deputy Director Darin Heard at: heardd@co.kern.ca.us
GENERAL
 
INFORMATION REQUEST
Department form for requesting public records.
 
PHYTOSANITARY CERTS
 
CANADA ORIGIN
CERTIFICATE
Canadian Food Inspection Agency Certificate of Origin for counties NOT regulated for LBAM (includes Kern County).
 
CDFA QUARANTINE
COMPLIANCE CERT.
Certificate of origin and treatment (if applicable) for commodities shipped from or through Kern County.
 
FEDERAL PHYTO -
ATTACHMENT FORM
Official Federal Phytosanitary Certificate Attachment Sheet (Form PPQ 575).
 
FEDERAL PHYTO -
MS EXCEL TEMPLATE
Microsoft Excel template for completing Federal Phytosanitary Certificates (Form PPQ 577).
 
FEDERAL PHYTO -
SUPERCEDE FORM
Request to replace a previously issued Federal Phytosanitary Certificate.
 
KERN TREATMENT -
REQUEST FORM
Notification form for pending treamtents or request to inspect export products under special program requirements.
 
PCIT
 
PCIT FACT SHEET
USDA Phytosanitary Certificate Issuance and Tracking (PCIT) System – Industry Fact Sheet.
 
USDA ADMIN FEE
 
CHECKS COLLECTED
WORKSHEET
Log for tracking the USDA Administrative Fee remitted in check form (for shippers using 4-part paper).
 
KERN COUNTY MEMO
Kern County memo providing information on the USDA Administrative Fee collection process and exemptions for voided phytos.
 
PHYTOS ISSUED -
INSTRUCTIONS
Instructions for completing the USDA Administrative Fee worksheet.
 
PHYTOS ISSUED -
WORKSHEET
Log for tracking Date, Applicant, and Certificate Number for issued Federal Phytosanitary Certificates (for shippers using 4-part paper).
 
USDA MEMO
USDA Administrative Fee announcement and information.
 

 

ENVIRONMENTAL PROTECTION

Forms and Documents

Contact Deputy Director Lanette Bankston at: bankstonl@co.kern.ca.us
APIARY
 
BEE MOVEMENT
Pin or unpin apiary locations for the Department's pesticide notification system.
 
BEE REGISTRATION
Beekeeper registration, apiary location(s), and request for pesticide notification form.
 
SEEDLESS MANDARIN
REGISTRATION FORM
Voluntary seedless mandarin grove registration.
 
FUMIGANTS
 
CHLOROPICRIN
Includes NOI requirements, bed/broadcast/drip tarp buffer zone tables, Emergency Preparedness & Response Requirements and map. (Effective January 01, 2017)
 
FIELD FUMIGATION MANAGEMENT PLAN
CA-DPR fillable pdf management plan for field fumigation (Form DPR-ENF-220).
(Revised December, 2012)
 
FIELD FUMIGATION
METHOD CODES
CA-DPR Volatile Organic Compounds (VOC) field fumigation codes for NOI's and PUR's.
(Revised August, 2014)
 
FIELD FUMIGATION
POST APPL. SUMMARY
CA-DPR fillable pdf field fumigation post-application summary (Form DPR-ENF-228).
(Revised December, 2012)
 
METAM SODIUM/
POTASSIUM
Approved metam application methods, NOI requirements, and acceptable and prohibited times/locations. Includes the Kern County Fumigation Summary form. (Effective January 01, 2017)
 
NON FIELD FUMIGATION MANAGEMENT PLAN
Management plan for non-field fumigation.
 
TELONE
Overview, application methods, and background information for 1,3-Dichloropropene pesticides (fumigants).
(Effective February 01, 2017)
 
PERMIT - CONDITIONS
 
 
CHLOROPICRIN
Includes NOI requirements, bed/broadcast/drip tarp buffer zone tables, Emergency Preparedness and Response Requirements & map. (Effective January 01, 2017)
 
CHLORPYRIFOS
General conditions and buffer zone requirements around sensitive areas. (Effective January 01, 2017)
 
DRIFT MINIMIZATION
Aircraft and ground drift minimization measures for restricted materials.
 
GENERAL
Kern County General Permit Conditions. (Effective January 01, 2017)
 
GWPA -
MANAGEMENT
Runoff and leaching management practices for Ground Water Protection Areas (GWPA). Includes pesticides subject to restriction and all classified Kern County GWP Areas (listed by TRS).
 
GWPA -
NON-PRODUCTION
Supplemental conditions for GWP Area materials when used at non-production and/or non-agricultural sites (non-site specific use).
 
HERBICIDE DRIFT
PREVENTION CONDITIONS
Kern County conditions to prevent herbicide drift. (Effective January 01, 2016)
 
METAM SODIUM/
POTASSIUM
Approved metam application methods, NOI requirements, and acceptable and prohibited times/locations. Includes the Kern County Fumigation Summary form. (Effective January 01, 2017)
 
PHENOXY
Allowed dates and restrictions for phenoxy applications. (Revised January 01, 2017)
 
TELONE
Overview, application methods, and background information for 1,3-Dichloropropene pesticides (fumigants).
(Effective February 01, 2017)
 
THIODAN
Runoff containment and conditions for endosulfan aerial applications.
 
PERMIT - GENERAL
 
LETTER OF
AUTHORIZATION
Authorization for anyone other than the permittee (the operator of the property, defined as the owner, partner or officer of the business applying for the permit) to sign the permit.
 
PERMIT SUPPLEMENT
Application for a Restricted Materials Permit supplement.
 
PERMIT - RESPIRATORY PROGRAM
 
MEDICAL QUESTIONNAIRE
Questionnaire for completion by each respirator-wearing employee.
 
MEDICAL QUESTIONNAIRE
SPANISH
Questionnaire for completion by each respirator-wearing employee.
SPANISH VERSION
 
PROCEDURES
Respirator selection, fit testing, training and evaluation for an organization's Written Work-Site Specific Procedures.
 
TRAINING FORM
Employee respirator assignment, fit test, training record, and consultation (Written Respiratory Protection Program - Attachment #1).
 
VOLUNTARY POSTING
Posting requirements for voluntary respirator use.
 
VOLUNTARY POSTING
SPANISH
Posting requirements for voluntary respirator use.
SPANISH VERSION
 
WORKSITES WITH IDLH
Supplemental program documentation for use of atmosphere-supplying respirators and work in IDLH atmospheres. (Written Respiratory Protection Program - Attachment #2).
 
MISCELLANEOUS
 
KERN COUNTY CROP
REPORT FORMS
 
DOWNLOAD INSTRUCTIONS - PERMITS
Instructions for downloading and viewing 1994 through current Restricted Materials Permit data.
 
DOWNLOAD INSTRUCTIONS - USE REPORTS
Instructions for downloading and viewing 1994 through current Pesticide Use Report (PUR) data.
 
INFORMATION REQUEST
Environmental and Public Protection Division information request. Use for Restricted Materials Permit and use report data requests. Note: Permit and use report data may be directly downloaded from our website.
 
NOI PILOT PROJECT
CONTACT PREFERENCES
Kern County grower contact phone and e-mail preferences for the Department's Notice of Intent Pilot Project to Protect Agricultural Workers.
 
PESTICIDE HANDLER
TRAINING RECORD
Form documenting requirements and completed training for individuals who work with pesticides.
 
PESTICIDE HANDLER
TRAINING RECORD
SPANISH
Form documenting requirements and completed training for individuals who work with pesticides.
SPANISH VERSION
 
PESTICIDE SAFETY
INFORMATION SERIES
PSIS-4  First Aid     SPANISH VERSION
 
REPORT OF LOSS
Environmental and Public Protection Division report of crop loss, nonperformance or damage.
 

 

MEASUREMENT STANDARDS

Forms and Documents

Contact Deputy Director Eddy Greynolds at: greynoldse@co.kern.ca.us
GENERAL
 
COMPLAINT FORM
Division form for reporting a business in violation of weights and measures standards.
 
CUSTOMER SATISFACTION
SURVEY
Customer satisfaction survey for Measurement Standards complaints.
 
INFORMATION REQUEST
Department form for requesting public records.
 
DEVICES
 
CALIFORNIA TYPE EVALUATION PROGRAM
Application for evaluation of a new Weighing or Measuring Device(s).
 
PLACED IN SERVICE
REPORT
Sample form for reporting placement after repair of a Commercial Weighing or Measuring Device.
 
SERVICE AGENCY APPLICATION
CDFA form for agencies registering to service Weights and Measures devices.
 
SERVICE AGENCY CANCELLATION FORM
CDFA form for agencies canceling their registration to service Weights and Measures devices.
 
MISCELLANEOUS
 
CONSUMER BROCHURE
CDFA Department of Measurement Standards consumer information brochure. Includes tips for the consumer and contact information.
 
WEIGHMASTER
 
COMMON TARE NOTICE
Notice of official tare and referenced weighmaster certificate number for posting at all weighing locations. Includes instructions.
 
WEIGHMASTER
LICENSING
Application for a new, renewal or updated Weighmaster License. Includes instructions.
 
WEIGHMASTER
LICENSE CANCELLATION
Form for canceling a Weighmaster License.
 
 

 



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2/28/2017
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