Restricted-Use Pesticide Sales and Storage                                                                           ____________ Reporting year                
                                                                                                                                                         Annual Report
                     Outlet & physical address ___________________________________________________________________________________
                     Dealer name(s) & certification number(s) _____________________________________________________________________
                     _____________________________________________________________________________________________________________________________________                                                                                                                                  
                                                                                                                                                                                                                                                                                                  No Sales  
                                                                                                                                                                   Solid (S) or  Total Amount Sold                              Total Amount in 
                             EPA Registration Number                                                       Name of Product                                          Liquid (L)                                                 Storage (Gal or Lbs)              County Code  Office Use 
                                                                                                                                                                                                 (Gal or Lbs)
                                                                                                                                                                  1 of 2                                                                                                                                                   DRAFT
                                                                                                                                Restricted-Use Pesticide Sales and Storage                                                                           ____________ Reporting year                
                                                                                                                                                         Annual Report
                                                                                                                                                                   Solid (S) or  Total Amount Sold                              Total Amount in 
                             EPA Registration Number                                                       Name of Product                                          Liquid (L)                                                 Storage (Gal or Lbs)              County Code  Office Use 
                                                                                                                                                                                                 (Gal or Lbs)
                                                                                                                                                                  2 of 2                                                                                                                                                   DRAFT