05 Attachment 4 - Pesticide App Record Report.pdf

This is a Pesticide Application Record Sheet form (CEMVR FORM 55-E) used by the Corps of Engineers, Omaha District to document pesticide usage at federal facilities. The form serves as a template for recording pesticide applications and can be used for either anticipated usage requests or actual usage reports.

The form requires documentation of the target pest, specific site description, pesticide product information (trade name, manufacturer, EPA registration number, EPA classification as general or restricted, and formulation type), application mixture ratios, application rates, and the number and timing of applications. For actual usage reports, the form captures the specific date and time of application, application equipment and method, applicator information (whether a Corps employee or contractor, including name, address, and phone number), total area of buildings treated, and total amount of pesticide used. For outside applications, the form documents environmental conditions at the time of application including wind speed and direction, temperature, humidity, and soil moisture conditions (wet, moist, or dry). The form includes fields for the field office location, preparer name and phone number, and date of preparation.