FORM V (C)

INTIMATION TO PERSON / LICENSEE FROM WHOM SAMPLE IS TAKEN

[Rule 33]
To,
KISAN MALL ,
D no: 1-1-7-4,Main road,
Pattikonda(M),Kurnool Dist.
PIN:518380.

I have this 08 day of month August.year 2019 taken from the premises of PATTIKONDA
KISANMALL,Dno:1-1-7-4,MainRoad,Pattikonda(M),KurnoolDist.(Sale/Stock/Distribution
License No:6454 ,dated:06/08/2018), situated at Pattikonda (Village&Mandal) Sample of the
insecticides specified below for the purpose of test or analysis.

Common Name of the Insecticide

1 (mention complete details like : Deltamethrin 11% EC
type of formulation)
2 Trade Name : decis
Bayer Crop Science
Limited,Regd.office:Bayer house,central
avenue,Hiranandani estate,Thane(West)-
3 Manufactured By (Full Address)
400607,village nimbua,P.OMubarakpur-
140201,Tahsil Dera Bassi,Dist:S.A.S
Nagar(Mohali),Punjab
CIR-202/2003(232)-Deitamethrin(EC)-
4 Registration Number :
02
5 Marketed By : Bayer Crop Science Limited
6 Manufacturing License No. : LCPP/ADO-13/Mfg-923
7 Batch Number : DESDB18031
8 Date of manufacture : 03/10/2018
9 Date of expiry : 02/10/2020
Stock before sampling (Mention
10 : 31 Bottles each 100 ml
Units)
Quantity of Sample Taken
11 : 100 ml
(Mention Units)
Stock after sampling (Mention
12 : 28 Bottles each 100 ml
Units)
Folio/Page Number of the Stock
13 283
Register
14 Any Other relevant Information -

Date: 08-08-2019 Signature of the Insecticides Inspector

with Seal
Signature of the Witness 1 (with Date, Name
and Address)

Signature of the Witness 2 (with Date, Name

and Address)

Received One Sealed Portion of the sample along with a copy of this form.

Signature of the person with Seal

 from whom sample is taken
FORM V (D)
FORM TO BE KEPT WITH SAMPLE IN SEALED PACKET
[SEE SUB-RULE (1) OF RULE 34]

To
The Deputy Director of Agriculture (IA),
Pesticides Testing Laboratory & Coding
Centre, Old Mirch Yard, Opp. Fire Station,
Nallapadu Road,Guntur – 522 004

Name of the Insecticide

(Common Name with active
1 : Deltamethrin 11% EC
ingredient and formulation
type

2 Batch Number : DESDB18031

3 Date of manufacture 03/10/2018

4 Date of expiry : 02/10/2020

Packing Condition (Original

5 : Sealed
Sealed/Loose)

6 Quantity of the Sample : 100 ml

7 Sample Drawn on : 08-08-2019

S.Saritha, Mandal Agriculture

8 Sample Drawn by :
Officer,Pathikonda Mandal

Specimen Seal of Insecticide

9 :
Inspector

Distinct Mark on the sealed

10 : 10/XXX/611
packet of the sample

Date: 08-08-2019 Insecticide Inspector

(Signature and Seal)
 FORM – V(E)
MEMORANDUM TO INSECTICIDE ANALYST
(See sub-rule (3) of Rule 34)

From
Smt.S.Saritha
Mandal Agricultural officer,
Pathikonda.

To
The Deputy Director of Agriculture(IA),
Pesticides Testing Laboratory & Coding
Centre, Old Mirch Yard, Opp. Fire Station,
Nallapadu Road,Guntur – 522004
Mobile No.8886614021

1. The portion of the sample / container described below is sent here with for the test
or analysis under the Rule 34 of the Insecticides Rules, 1971.

a) Technical Name of the

Insecticide: (nominal content, : Deltamethrin 11% EC
type of formulation etc.)
b) State of packing of the sample : Sealed Bottle
c) Specimen Impression of the seal
of the Inspector
:

2. The portion of the sample / container has been marked by me with following
marks.

Code No. 10/XXX/611

3. A copy of this Memorandum along with a Form V (D) has been send Separately
with the sample by registered post or by hand.

Place:Pathikonda
Date:08-08-2019

Insecticide Inspector
Signature & Seal
 DOCKET SHEET

1 Name of the District : Kurnool

2 Sample drawn by
a) Name : S.Saritha
b) Designation : Mandal Agriculture Officer,Pathikonda
3 Name of the Chemical
a) Trade Name : Decis
b) Technical Name : Deltamethrin 11% EC
4 Guaranteed % of A.I : 11%
5 Qty of sample drawn for
: 100 ml
analysis
6
Name of the dealer from KISANMALL Dno:1-1-7-4,Survey
: no:686/A,Mainroad,Pattikonda(M)
whom the sample drawn
KurnoolDist. PIN:518380
sri venkateswara commercial
7 Name of the distributor :
corporation
8 Name of the Marketer : Bayer Crop Science Limited
9 Bayer Crop Science
Limited,Regd.office:Bayer house,central
Name of the manufacturer avenue,Hiranandani estate,Thane(West)-
:
along full address 400607,village nimbua,P.OMubarakpur-
140201,Tahsil Dera Bassi,Dist:S.A.S
Nagar(Mohali),Punjab
10 Batch Number : DESDB18031
11 Date of manufacturing : 03-10-2018
12 Date of expiry : 02-10-2020
13 Date of drawl of sample : 08-08-2019
14 Date of receipt of stock by
the Dealer and from whom : 30-06-2019
received
15 Particulars of invoice : 143
16 Stock position of batch at
the time of drawl of : 31 Bottles each 250 ml
samples
17 I.SI. Marks(if any) :
18 Code No.of A.O : MAO/PKD/P-5/19-20
19 Q.C.I seal particulars :
20 CA’s seal particulars : 10/XXX/611
Deputy Director of Agriculture, Pesticide
Name of the P.T.L to which
21 : Testing Laboratory & Coding Centre,
sent for analysis Guntur
22 Date of Dispatch : 08-08-2019

Insecticide Inspector
Signature & Seal