Untitled Document

Pesticide Misuse Reporting System

Name
Address
Town
Phone #
e-mail
Location of Incident	ie. Farm, Road, Home

Applicator or Company	* if known*
Product	* if known*
Is Emergency Response Required ?	Yes	No
Is Surface Water Being Affected ?	Yes	No
Are There Environmental Concerns?	Yes	No
Are There Human Health Concerns ?	Yes	No
Time of Incident
Date of Incident

Please Provide a Description of the Allegation or your Concerns Below;

Other Important Numbers

Vermont Department of Agriculture
116 State St. Montpelier VT 05602
(802) 828-2431

Vermont Poison Center
Fletcher Allen Health Care
111 Colchester Avenue Burlington, VT 05401 Emergency Phone:
(877) 658-3456
(802) 658-3456

Vermont Emergency Management
103 South Main Street Waterbury, VT 05671-2101 (802) 244-8721
1-800-347-0488