HomeMy WebLinkAboutEI du Pont de Nemours and Company-5/7/20124
DuPont Imprelis® Claims Resolution Process
c/o Epiq Systems
PO Box 4834, Grand Central Station
New York, NY 10163-4834
April 16, 2012
VIA UPS OVERNIGHT
CITY OF WATERLOO LEISURE SERVICES/GATES PARK GOLF COURSE
ATTN: TODD DERIFIELD
1101 CAMPBELL AVENUE
WATERLOO, IA 50701
Re: Claim Number(s): 9000629
Property Location: 820 EAST DONALD STREET
WATERLOO, IA 50703
E.I. du Pont de Nemours and Company ("DuPont") has evaluated the claim(s) you filed with the
Imprelis® Claims Resolution Process for the above -referenced property. This notice only
applies to the property identified above. If you submitted information about other properties,
separate notice letters have been or will be issued to you.
If you agree to the terms of the enclosed Claim Resolution Agreement ("Agreement"), DuPont
offers to:
• Remove 5 specified tree(s) from your property.
• Pay you $29,000.00 that you can use to arrange for the replacement of those 5 tree(s).
• Pay you $750.00 to provide new tree maintenance for your replacement tree(s).
• Pay you $1,169.00 that you can use to purchase tree care for 4 other tree(s) remaining on
your property.
• Give you a limited warranty for damage (if any) to trees caused by Imprelis® arising in
the future.
• Pay you an additional $5,275.35 in compensation.
Detailed information about each of these offers is provided in the enclosed Agreement.
In agreeing to accept services and payment from DuPont relating to trees on your property, you
must also agree to several other terms, including, but not limited to, a release waiving your right
Claim Number: 9000629
Page 2
to file or participate in any lawsuit related to Imprelis®, an agreement to bring remaining
disputes in arbitration, and a waiver of your right to a jury trial. Please read this enclosed
Agreement in its entirety. You may seek the advice of counsel of your choosing at any time
before signing the Agreement.
When you have signed the Agreement, please return all of the pages of the Agreement (including
the Tables) to:
If by regular mail:
Imprelis Claims Resolution Process
c/o Epiq Systems
P.O. Box 4834, Grand Central Station
New York, NY 10163-4834
If by overnight mail:
Imprelis Claims Resolution Process
c/o Epiq Systems
757 Third Avenue, 3rd Floor
New York, NY 10017
Once DuPont receives the signed Agreement, it will begin the process of arranging for tree
removal and other steps, as applicable and consistent with the Agreement. Payments will be
made via check and sent to the address indicated at the top of this letter.
If you do not agree with any of the terms set forth in the attached Tables, please provide your
reasons in writing within 30 days to DuPont at the above -identified Imprelis® Claims Resolution
Process address. Please include in your submission: (i) your claim number (ii) a statement
detailing the basis for your disagreement; (iii) copies of any document or other writing upon
which you rely; and (iv) your address, phone, and e-mail contact information. DuPont will only
consider disagreements with the information and recommendations that appear in the attached
Tables.
DuPont intends for this Agreement to provide resolution of your Imprelis®-related claims and is
hopeful that it will meet with your satisfaction. If you have any questions or concerns about the
Imprelis® Claims Resolution Process, please contact DuPont at 1-866-796-4783.
Claim Number: 9000629
Page 3
Please read this entire Claims Resolution Agreement ("Agreement") carefully. By signing
the Agreement, you agree to be bound by all of the terms and conditions set forth below.
CLAIM RESOLUTION AGREEMENT
This Claim Resolution Agreement ("Agreement") is entered into between E.I. du Pont de
Nemours and Company ("DuPont") and an authorized owner of the property at 820 EAST
DONALD STREET, WATERLOO, IA 50703. The authorized Owner ("Owner") represents that
he or she holds title to the property at issue, and that all other persons or entities holding a fee
simple, leasehold or other possessory interest in the property have authorized Owner to execute
this Agreement, to bind them to the terms thereof, and to make choices about and receive
services and payment on their behalf.
TREE REMOVAL AND REPLACEMENT
There may be laws or regulations and/or neighborhood or homeowner association rules that
address tree removal or replacement. Before any removal and/or replacement of trees can take
place under this Agreement, Owner must make sure that such action is in compliance with such
laws, rules and/or regulations.
REMOVAL AND DISPOSAL
Service: DuPont recommends removal for all trees listed in Table 1. DuPont will arrange for
proper removal and disposal of these trees by paying a tree removal company directly for this
service on Owner's behalf. Owner has the right to obtain and to retain samples from such trees
or other materials of Owner's choosing. If Owner so chooses, Owner should arrange at Owner's
expense to obtain and/or retain such materials. If trees listed in Table 1 have already been
removed and disposed of properly, DuPont will pay Owner an amount to compensate Owner for
removal of those trees.
REPLACEMENT
Payment: DuPont offers to pay Owner $29,000.00 for the value of the trees listed in Table 1.
Owner shall decide how to use this compensation and is not bound to purchase replacement
tree(s). If Owner opts to use this compensation to replace trees, replacement tree or trees of the
Owner's choosing may be purchased from (a) one of DuPont's designated qualified tree
replacers or (b) a tree replacer of the Owner's choosing. A list of designated qualified tree
replacers is available at www.imprelis-facts.com. If Owner decides to purchase replacement
tree(s) from a tree replacer other than those listed on the designated qualified tree replacer list,
the Limited Warranty for new trees identified below may not apply. Not all trees (particularly
trees greater than 20 feet tall) will be able to be replaced with precise equivalents. Table 5
represents a listing of tree replacement prices that have been agreed to by DuPont's designated
qualified tree replacers for the particular species of trees to be removed from Owner's property.
If Owner is unable to arrange for tree replacement with another tree or trees of the same species
Claim Number: 9000629
Page 4
from one of DuPont's designated qualified tree replacers at the prices set forth in Table 5, Owner
may contact DuPont at 1-866-796-4783 for assistance. DuPont will work with its designated
qualified tree replacers or another company to ensure that, if Owner so chooses, Owner can
receive another tree or trees of the same species at the value promised.
New Tree Maintenance: In addition, DuPont will pay Owner $150.00 per removed tree for new
tree maintenance of any replacement trees.
Qualified Tree Replacer Limited Warranty for Replacement Trees: Each replacement tree
planted by DuPont's designated qualified tree replacers will be covered by a two-year
replacement guarantee supported by DuPont's designated qualified tree replacers. If Owner
believes that the tree replacement guarantee is not being honored by DuPont's designated
qualified tree replacers, Owner should contact DuPont at 1-866-796-4783 for assistance.
Any replacement tree will be planted in a workmanlike manner according to standard industry
practice. Subject to the limitations below, any replacement tree that does not survive the period
extending two years from the date of planting will be replaced by a tree of the same or similar
value. A tree will only be replaced once during the warranty period. A new guarantee will not
extend to a replacement tree planted during the warranty period.
The warranty excludes any damage to a tree outside of DuPont's designated qualified tree
replacers' control and specifically excludes any tree damage resulting from acts of nature such as
severe weather conditions, wind, hail, low temperature, drought, flooding, or storm damage;
damage caused by humans or animals, including mowing, plowing, digging; damage caused by
insects or disease; and damage attributable to an Owner's failure to properly care for a
replacement tree, such as improper watering, pruning, and fertilization. The limited warranty
provided by DuPont's designated qualified tree replacers excludes any tree damage relating to
Imprelis®.
TREE CARE
Payment: DuPont recommends tree care for the trees listed in Table 2, as care is required for
these trees to have the best chance to thrive. DuPont will pay Owner $1,169.00 so that Owner
can provide tree care for each of these trees. DuPont recommends that Owner consult an arborist
or lawn care professional for assistance in purchasing and/or ascertaining proper tree care for the
trees listed in Table 2. Tree care for each tree may include pruning, shaping, watering, insect
spraying, and other care.
Reassessment. If a tree receiving tree care remains alive at the end of the DuPont Limited
Warranty period set forth below, but Owner reasonably believes that it will not recover because
of its exposure to Imprelis®, DuPont will, at Owner's request, reassess the tree for possible
removal and replacement or reasonable compensation. If a tree receiving tree care dies during
the DuPont Limited Warranty period set forth below because of its exposure to Imprelis®,
DuPont will arrange to remove and replace the tree or provide reasonable compensation for the
value of the tree. Owner should make any requests under this subparagraph by calling
1-866-796-4783. DuPont will not be responsible for reassessment, removal, replacement or
Claim Number: 9000629
Page 5
compensation for any tree for which Owner has failed to provide appropriate care. When
requesting reassessment of a tree, Owner agrees to provide adequate documentation, such as
receipts, invoices, or other information, to verify that the Owner provided appropriate tree care
to the trees identified on Table 2.
Important: If Owner removes (or authorizes anyone else to remove) any tree identified on
Table 2 at a future time, Owner agrees that the removal and disposal will be performed in
accordance with the instructions listed at www.imprelis-facts.com.
ADDITIONAL PAYMENT
In addition to the above, DuPont will make an additional payment to Owner. The amount of the
additional payment is listed in the bottom row of Table 4, and represents 15% of the total value
of the other payments and services DuPont is providing. This additional payment of $5,275.35 is
intended to compensate Owner for all other potential Imprelis®-related claims against DuPont
that may exist, including but not limited to any claims for loss of aesthetic enjoyment; loss of
use; loss in property value; or claimed damage to other trees, shrubs, grasses, or other plants.
DUPONT LIMITED WARRANTY
DuPont warrants against any damage to any tree on Owner's property (including replacement
trees) caused by Imprelis® until December 31, 2013, or in the case of replacement trees, until a
date two years after the date of planting. In the event that the Owner's property is sold, this
limited warranty transfers with the property to the new owner. If Owner believes that a tree
covered by this warranty has experienced damage caused by Imprelis®, it shall promptly inform
DuPont by sending a letter detailing such damage and the reason Owner believes it is caused by
Imprelis® to:
DuPont Imprelis® Claims Resolution Process
c/o Epiq Systems
757 Third Avenue, 3rd Floor
New York, NY 10017
This warranty does not apply to trees recommended to receive tree care for which Owner has
failed to provide appropriate care.
RELEASE AND NOTICE
As consideration for the above, Owner agrees to forever release, acquit, and discharge DuPont,
any third -party individuals or entities that applied or arranged for the application of Imprelis® on
Owner's property, and any Imprelis® distributors; and all of their respective principals, agents,
officers, directors, stockholders, owners, partners, employees, attorneys, sureties, insurers,
successors, predecessors, assigns, and all affiliated corporations and entities, including their
sureties, insurers, and attorneys, and each of them (collectively, the "Released Parties") from any
and all liabilities, actual and potential claims, demands, and causes of action, of whatever nature,
whether known or unknown, foreseen or unforeseen, asserted or unasserted, that exist between or
among Owner and any Released Party or Parties as related to Imprelis® or the application of
Claim Number: 9000629
Page 6
Imprelis® to the Owner's property, this Agreement and the events surrounding its negotiation
and execution, including but not limited to claims for fraud and fraudulent inducement. This
release does not include claims made under the DuPont Limited Warranty.
Owner and DuPont agree that no medical claim has been made or released by Owner that would
implicate the Medicare Secondary Payer Act or the Medicare, Medicaid, and SCHIP Extension
Act of 2007.
In executing this release, Owner understands and acknowledges that it may discover facts
(including but not limited to facts about Imprelis® or DuPont) or damages, or incur damages that
were unknown or unanticipated at the time this Agreement was signed. Even so, Owner
expressly, knowingly, and voluntarily agrees that Owner's decision to enter into this Agreement
is made with regard to such possible future discoveries, and the Agreement cannot be reopened
in light of any such future discoveries.
NOTICE: DuPont advises Owner that other property owners have filed lawsuits against
DuPont, including those seeking to certify class actions of which Owner may be a putative
member. These lawsuits allege, among other things, that DuPont failed adequately to test
Imprelis® before releasing it to the market and failed to include appropriate warnings
about the harm that Imprelis® could cause to non -target vegetation. Plaintiffs in these
lawsuits seek compensatory damages, statutory damages, punitive damages, and other
types of relief that may be greater than that available in this claims process.
Many of those lawsuits have been consolidated in In re Imprelis Herbicide Marketing,
Sales Practices and Products Liability Litigation, Case No. 2:11-md-02284-GP in the U.S.
District Court for the Eastern District of Pennsylvania. The Court has appointed the
following counsel for Plaintiffs:
Liaison Counsel
• Robert Kitchenoff of WEINSTEIN KITCHENOFF & ASHER LLC, 1845 Walnut
Street, Suite 1100, Philadelphia, Pennsylvania 19103, (215) 545-7200.
Co -Lead Counsel
• Richard J. Arsenault of NEBLETT, BEARD & ARSENAULT, 2220 Bonaventure
Court, P.O. Box 1190, Alexandria, Louisiana 71301, (800) 256-1050;
• Adam J. Levitt of WOLF HALDENSTEIN ADLER FREEMAN & HERZ LLC, 55
West Monroe Street, Suite 1111, Chicago, Illinois 60603, (312) 984-0000;
• Hollis L. Salzman of LABATON SUCHAROW LLP, 140 Broadway, New York, New
York 10005, (212) 907-0700; and
• Jonathan D. Selbin of LIEFF CABRASER HEIMANN & BERNSTEIN, LLP, 250
Hudson Street, 8th Floor, New York, New York 10013, (212) 355-9500.
Copies of any complaints are available on request from DuPont. By signing this release, in
Claim Number: 9000629
Page 7
exchange for the relief provided by DuPont, Owner is foregoing any right to participate in
any of these other actions or to otherwise file suit against DuPont for claims released.
OWNER UNDERSTANDS THAT IT HAS THE RIGHT TO SEEK LEGAL COUNSEL
OF OWNER'S OWN CHOICE BEFORE SIGNING THIS AGREEMENT.
NO ADMISSIONS OR CONCESSIONS
This Agreement shall not in any way be construed or deemed to be evidence or an admission or a
concession of any fault, liability, fact or amount of damages, or any other matter whatsoever on
the part of any party to this agreement.
OWNER'S REPRESENTATIONS, COVENANTS, AND WARRANTIES
Owner represents, covenants, and warrants that:
• it has not assigned, transferred, encumbered, or otherwise impaired its rights to settle any
claims released by the Agreement; AND
• it will pay or otherwise resolve all known liens asserted in or arising out of this matter,
including any liens asserted by Owner's attorney, insurers or others.
ARBITRATION AGREEMENT
Owner and DuPont agree that any and all claims or disputes of whatever nature between Owner and
DuPont and/or any Released Party or Parties that arise out of or relate to Owner's claims, Imprelis®,
or this Agreement (including but not limited to those relating to the DuPont Limited Warranty, this
Agreement and the events surrounding its negotiation and execution) in any way must be resolved
through mandatory, binding arbitration, rather than litigation in court. This Agreement shall be
enforced pursuant to the Federal Arbitration Act, 9 U.S.C. § 1 et seq. An arbitrator, not a judge or
jury, will decide any dispute. DuPont and Owner hereby specifically waive any right to trial by
iury. If any part of this paragraph is found to be unenforceable by any court or arbitrator, then the
Agreement is invalid.
a) Class Action Waiver. Owner agrees that any and all claims or disputes between it and any
Released Party or Parties that arise out of or relate to this Agreement (including the DuPont
Limited Warranty) in any way will be arbitrated on an individual basis and that there will be
no class or representative actions in arbitration. Owner agrees not to participate in a class or
representative action against any Released Party or Parties and agrees to affirmatively opt out
of such a class, if the class action asserts claims that would fall within the scope of the
Release if they were asserted directly by Owner. Owner and DuPont agree that this class
action waiver is an essential part of this Agreement and that the class action waiver may not
be severed from this Agreement. If this class action waiver is found to be unenforceable by
any court or arbitrator, then the Agreement is invalid.
b) Choice of Arbitrator, Fees and Costs. All arbitrations shall be conducted before the CPR
International Institute for Conflict Prevention and Resolution (www.cpradr.org, 1-212-949-
6490). The CPR Fast Track Arbitration Rules will apply in any arbitration. Arbitration fees,
Claim Number: 9000629
Page 8
not including attorney's fees and costs, shall be borne by DuPont.
c) Limit on Relief in Arbitration. DuPont and Owner agree that an arbitrator may only award
such relief as a court of competent jurisdiction could.
MISCELLANEOUS
Mandatory Disclosures. State and local laws may require that Owner disclose to potential
buyers the existence of pending Imprelis® claims, as well as the warranties set forth in the
Agreement. Owner may consult with an attorney of its choosing at any time regarding
disclosure obligations that may arise during sale of this property.
Choice of Law. This Agreement is made and shall be construed, interpreted, enforced, and
governed in all respects under the laws of the State of Delaware, without giving effect to any
choice of law or conflict of law provision or rule that would cause the application of the laws of
any other jurisdiction.
Severance. Aside from specific exceptions explicitly noted in the Agreement, if any provision,
or any portion of any provision, of this Agreement is held to be illegal, invalid, or contrary to
public policy by a court of competent jurisdiction, such provision shall be deemed to be severed
and deleted; neither such provision, nor its severance and deletion, shall affect the validity of the
remaining provisions of this Agreement.
Integration. This Agreement memorializes and constitutes the entire agreement and
understanding between and among DuPont and Owner, and supersedes and replaces all prior
negotiations, proposed agreements, and agreements, whether written or unwritten. Owner
acknowledges that no Released Party, or any agent or attorney of any Released Party, has made
any promise, representation, or warranty whatsoever respecting this Agreement, and that Owner
has not relied on any such promise, representation, or warranty.
Heirs and Successors Bound. This Agreement shall be binding upon and inure to the benefit of
DuPont and Owner hereto and their respective heirs, personal representatives, successors and
assigns, and any corporation, partnership or other entity into or with which any party hereto may
merge, consolidate or reorganize.
Claim Number: 9000629
Page 9
DuPont and Owner have fully read and understood the terms and conditions above, and agree to
be bound by them.
Signed,
E.I. du Pont de Nemours and Company
Carl A. Malatesta
Manager Claims Resolution
Authorized Property Owner
If signature is by a trustee, executor, administrator, attorney-in-fact, officer of a corporation or
other acting in a fiduciary or representative capacity, it must be so indicated and proper
evidence of authority satisfactory to DuPont, must be submitted. A tax identification
number must be provided for all non-residential properties, including golf courses, corporations,
and companies.
The Property Owner must have a witness present when signing this Agreement. The witness
must then sign the signature line below and provide the specified contact information. The
Owner must return all pages of the Agreement (including the Tables).
The dersigned repents that
I; a full authQ:
ignature
Printed Name
Title (if apph ble)
E
I VVOt4e,I-4
Business Name (if applicable)
SAL6a 5%7
Social Security or Tax ID No.
Required for Payment Purposes
rir ?'4 / g ----
Date
Date
Altd, t.Srt
Address
�t--°t439,3
3
Telephone Number
Claim Number: 9000629
Page 10
TABLE 1
TREES RECOMMENDED FOR REMOVAL AND REPLACEMENT
Tree No.
Tree Species
Height (feet)
Removed Tree Value
1/3679
Spruce Norway
37
$6,500.00
2/3671
Spruce Norway
37
$6,500.00
3/3682
Spruce White
27
$4,000.00
4/3676
Spruce White
27
$4,000.00
8/4436
Spruce Norway
44
$8,000.00
TABLE 2
TREES RECOMMENDED FOR CARE
Tree No.
Tree Species
Height (feet)
Service Value
5/4479
Spruce Norway
36
$209.00
6/4778
Spruce Norway
39
$360.00
9/4476
Spruce Blue
23
$300.00
10/4475
Fir Concolor
23
$300.00
TABLE 3
TREES RECOMMENDED FOR NO ACTION
Tree No.
Tree Species
Height (feet)
7/4514
Buckeye
26
11/4477
Fir Balsam
29
12/32272
Spruce White
4
13/4732
Spruce Blue
14
Claim Number: 9000629
Page 11
TABLE 4
VALUE OF COMPENSATION/SERVICES
Category
Service or Payment
Value
Trees to be Removed
Service
$4,250.00
Removed Tree Value
Payment
$29,000.00
Replacement New Tree Maintenance
Payment
$750.00
Care for Existing Trees
Payment
$1,169.00
Total Claim Value
$930
$35,169.00
Additional Compensation -- 15% of Total Claim Value
Payment
$5,275.35
TABLE 5
REPLACEMENT VALUE TABLE
1' H
2-4' H
5-6' H
7-8' H
9-10' H
11-12' H
13-14' H
15-16' H
17-18' H
19-20' H
$30
$90
$230
$360
$520
$650
$930
$1,000
$1,120
$1,910
nut USBC • —
Impretis, Et AL
0040000 (MP)
0009000629
IiI
IIIIRIIIIIII1
IMPRELIS® Claim Form for Golf Courses' -
This Imprelis® Claim Form must be completed and postmarked no later than November 30, 2011.
The Property Location ID is: 3 3 / 2 7 8 2
9 /
A. GOLF COURSE LOCATION:
Golf Course Name: Cr y UcY 4 »I? %a ' f-4"' t° `-i'M.r'ar r-'71-/169,JC,0,T tilt eCovi<"
Address: g!a? 0 .4. . .s.- //57 itY: b' .r /a
Address Line 2: State, Zip Code: .Z, 5 Pow
Contact First Name: 7-a p/c1 . Phone Number: (3/ /, 02 ?Y." yj .26).
Contact Last Name: ,9g, ? 'VGr 4,7/949-.. Email Address: Trd h cie,f0 6,e/4/ 4,.# J:,,,c,/6;a,
Mailing address, if different from above: I.4 , 0.e,
Address: /1 U/ L ,f/0Y/J ht7f4-city: /go,�4.0,
•Address Line 2: N State, Zip Code: 11,9— -5 d g,'
Please indicate preferred means of contactE
✓✓✓✓✓✓mai1 • Phone
I have confirmed that the pmperty owner has not retained a lawyer related to this claim: )Yes
B. IF AN INSURANCE CLAIM HAS BEEN FILED, PROVIDE INFORMATION BELOW:
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Insurance Company: f tJ (/ 4r .41 Address:
---
Last Name: . Address Line 2:
First Name: �---.. City: "r—
Phone Number: State; Zip Code: -mow
Email Address: ----- Claim No. (if known):
Has the golf course received payment from an ' surance company related to impacted trees listed on Tree Detail
Listing (Section C of Claim Form)? 0 Yes or No
If yes, please detail amount received, and recipient: /1/J
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OCT 11. 2011
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Site Map
Note: Number each tree on map to 3 match Tree Number on Tree Detail Listing.
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E. EPA QUESTIONNAIRE:
Property Location ID:
33/3'7`/x?
The U.S. Environmental Protection Agency (EPA) has requested that DuPont ask the following questions about
this property and trees on this property. Please answer these questions to the best of your ability. If you do not
know the answer, indicate "unknown."
* * *
L When were adverse impacts attributed to Imprelis® first noticed on this property? Date: Tits{ /fq 2d//
2. How many applications of Imprelis® occurred on this property before adverse impacts were reported? 1
3. Did irrigation occur on this property after the application of Imprelis®? XYes 0 No 0 Unknown
a. If yes, what is the approximate number of gallons of water applied? '4/e,Ndcdit'
b. If yes, did the irrigation water come from a recovery reservoir or pond? 0 Yes,No 0 Unknown e'4,
4. Have you conducted any testing for Imprelis® in soil on this property? 0 YeNo 0 Unknown
a. If yes, were any Imprelis® residues detected? 0 Yes 0 No 0 Unknown tiliSL
5. Have you conducted any testing for Imprelis® in plant tissue collected from this property? 0 Yes 0 Np'Unknown
a. If yes, were any Imprelis® residues detected? 0 Yes 0 No 0 Unknown /l/�
F. DECLARATION:
Golf Course Professional — I certify that (a) the information I have provided for this Claim Form is true and
correct to the best of my knowledge, information and belief, and (b) Imprelis® was applied during 2011 to the
property detailed on this Claim Form.
Date:
Name (please print): -J 0.&eS B `g
Signature:
Title: C70
IC /' cL')q er-
g.
4 . . .
G. DUPONT REPRESENTATIVE AND GOLF COURSE CONSENT FORM:
Property Location ID: 3 3 k? 7 re -7
DuPont Representative — I agree to collect accurate information and documentation relating to trees at the above
property location, as authorized, and to provide such information and documentation to DuPont for the purpose of
assessing property owner's claims relating to trees believed to have been impacted as a result of an Imprelis®
herbicide application. I will only enter onto property owner's land at mutually agreed upon time(s).
Date: /a/9/12//
Name
Name (please print):/,%f/)11/ ,7'
Signature:
Golf Course Professional — I authorize the DuPont representative to collect information relating to trees at the
above property location, including details about and photographs of those trees, and to provide such
documentation for purposes of assessing any claim relating to trees believed to have been impacted as a result of
an Imprelis® herbicide application. I will provide the DuPont representative with authorization to access my
property for purposes of gathering this information at mutually agreed upon time(s). I understand that collection
and provision of this information to DuPont may directly affect the resolution of my claims through DuPont's
claims process.
Note: To receive the benefits set forth in the reimbursement plan for your property, you will be required to sign a
release that waives your right to file or participate in any lawsuit related to Imprelis®. By signing this Claim
Form, however, you are not waiving any rights; you are only permitting DuPont to assess your property and offer
you a remediation plan. You may seek the advice of counsel of your choosing at any time during this process.
Date: 10- 7- I
Name (please print): J a 14 5 V.*1 er
Signature:
Title!
ol-C Mitt „qg er
PESTICIDE APPLICATOR RECORD
CITY OF WATERLOO, IOWA
LEISURE SERVICES COMMISSION
1101 CAMPBELL AVENUE
WATERLOO, IA 50701
(319) 291-4370
STATE OF IOWA APPLICATOR LICENSE #P000378
DATE PESTICIDE APPLIED: 5 / IR / 11
Name of Applicator: (:' `42.v.. r' I f es- Certificates#: 01 ko 3
Place of Application (specific location): Co A -A -c POr G C. -C,4 j c t,Jat i S
P a- 10
13' N‘ la,1 .Y1 j Te -e.4 -9 11-18i)
fi r� •v 5 e 1.--E0) (0-- C7 ) P rr' s k 6 P /1-1: 'O\
Target Pest (problem to be controlled): 1,1d-ee.,A. s r_ r ()%6 tj rry c. S
Time of Day Pesticide Applied (be specific): 7r4,m 0 p i
Temperature: 70,D Wind Direction and Estimated Velocity: ,sem opI)
Trade Name of Product(s) Used: 0i raj ,.e0 S i o cit yy) re r J 1
EPA Registration Number.
lot - c42,
35a -?q3
Total Quantity of Product Used: 35 4 t s
Size of Application Area (acres or square ft.): 1 1. 4U%
3 A oZ D ot. /00,41
Concentration of Mixture Used:
Rate of Application (lbs/acre, etc.):
Type of Application Equipment Used:
Additional Comments:
1.3p}s kres • 3" oz1:401w
o P((� td -C" T �i t r uc-Vtonl
9 i kJ0zz..
10/2006
PESTICIDE APPLICATOR RECORD
CITY OF WATERLOO, IOWA •
LEISURE SERVICES COMMISSION
1101 CAMPBELL AVENUE
WATERLOO, IA 50701
(319) 291-4370
STATE OF IOWA APPLICATOR LICENSE #P000378
DATE PESTICIDE APPLIED: Ill..17L 2011
Name of Applicator: C /p yi n Pr Certificate #: 0/6,2_1
Place of Application (specific location): GA -4e4 �(�'�.G..C_ .- 4.i Ywals
F� ;�'3� Li S. 6.� 7� e� IUB 13} 1 1) iso 18
Target Pest (problem to be controlled):
Gf0.ki)(5rtas5 dee-&S
Time of Day Pesticide Applied (be specific): 7 qrn - D3 0 pry)
Temperature: 4° Wind Direction and Estimated Velocity: 5VJ S--/Zniph
Trade Name of Product(s) Used: f y y rJS/0k) QJ . -I'm per 1/5
EPA Registration Number: 21 jq — 5y2. 3S2 -773 3
Total Quantity of Product Used: 6-9411 lit 19062—
Size
90eZSize of Application Area (acres or square ft.): 31 P2_ Aces
Concentration of Mixture Used: 3$4. Q0 02- /oo 020
Rate of Application (lbs/acre, etc.): Ae✓P_ 4,57.o-2,1,0ALej4..a
Type of Application Equipment Used: J I spoil er - 4;c i i I c1 u4. -1--i0-6,1 t j p files
Additional Comments:
10/2006
Sender. You must seal flap before shipping.
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