Number: ______

/ Landholder Consultation Record

Instructions: Complete to provide a record of consultation prior to locust spraying on a property.

1.  Landholder Details

Property Name / Consultation Date
Owner/Occupier’s Name / Signature
GPS location of report
Address
Home telephone / Mobile
Fax / UHF
Email address

2.  Locust Details – confirmation of report

Stage
Activity
Density
Area Affected (ha)
Reason for non-inspection
Insecticide issued / Litres / Ha to be treated
LLS Officer (name) / Date

3.  Information provided/discussed

“Australian plague locusts, landholder control strategies for NSW” Brochure / Insecticide label / Contact numbers for enquiries
Safemeat “Plague locusts, wingless grasshoppers and livestock residues” brochures / Insecticide SDS / Transport of insecticide by landholder
WHS legislation and Pesticides Act 1999 / Permit / Other (please specify)

4.  Identified Potential Hazards (tick if present)

Aquaculture / Crop Harvest Schedule / Livestock Market Schedule
Organic Production / Quality Assurance / Endangered Species
Apiary Sites / Traditional Gathering Activities / Biological Control Program
Feral/Wild Animal Harvesting
/ Chemically Sensitive Persons / Stock on TSR
Lambing Ewes/Calving Cows / Horses / Neighbouring Properties
Dry Gullies / Water bodies (inc Farm Dams / Other – please list

5.  Permission to Spray

Written permission obtained in advance of anticipated, subsequent spraying (see below)
Prior full consultation and provision of information
Final verbal information that spraying imminent (mandatory on actual day of, and prior to, spraying)

6.  Authorisation to Spray

I …………………………………………………………………………………………….….
Being the occupier or duly authorised person of the occupier of the property/s
…………………………...... situated at ………………………………………..
within the ………………………. Local Land Service region give permission for
the NSW Department of Primary Industries (NSW DPI)/ …………………….… Local
Land Service (LLS)/Australian Plague Locust Commission (APLC) to carry
out aerial/ground* spraying of the insecticide …………………………….. or other control agents
……………………….…..… to control pest insects on the above property/s during the period
………………..…………. to ………………..…………. .
In giving this permission I acknowledge that:
I have been advised of my responsibilities under the Pesticides Act 1999 and have been provided with information on the insecticide to be used, the withholding period and any other requirements which may affect crops, pastures and livestock on the above property/s.
I have authority to give this permission on behalf of all other occupiers of this property/s.
I agree to implement any conditions required by the label of the insecticide used.
NSW DPI/LLS/APLC* will comply with all provisions of the Pesticides Act 1999 and other relevant legislation and will exercise due care and responsibility in the storage, transport, handling, application, and disposal, of the insecticide and containers.

7.  Issue of locust spray/mister unit

Instructions on the use of the spray unit
Acknowledges need to comply with WHS legislation & Pesticides Act 1999 in relation to the use of spray equipment and the recording of spray applications on the land they occupy, manage or own.
Tracking # of unit issued / Date issued
Date when spray/mister is expected to be returned
Issued by (name)

8.  Acknowledgement * Strike out whichever not applicable

Name / LLS/NSW DPI/APLC* / Signature / Date
Name / Owner/occupier / Signature / Date

Record: Copy to owner, file with Registry

Landholder Consultation Record V5 6 January 2015 Page 1 of 2

(INT10/66341)