Attachment_1_Treatment_Reporting_Form.docx
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- Solicitation number
- 1224H819R0002
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Attachment 1 Treatment Reporting Form
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Text version
Attachment 1: Treatment Reporting Form Project Area Name: _______________ Date:_________________ Contract Information Contract Number:
PA Certified Pesticide Applicator License Number
Contractor Name:
Expiration Date
Address:
Contractor’s Personnel on Site
Phone Office:
Phone Cell:
Site Information
Temperature0F
Rainfall anticipated within the next 4 hours (Yes/No)
Weather (Sun, Partly Cloudy, or Cloudy)
Rainfall within last 24 hours (Yes/No)
Wind Speed (MPH) Required for Herbicide Treatment Open area <10mph Closed Canopy <4 mph
| Record mph at site |
| Slope % |
Traffic Control Devices in Place (Yes/No) If no explain.
Notification Signs in Place (Yes/No) If no explain.
Treatment Information
Treatment Type Check all that apply Low-volume foliar
| High-Volume foliar |
| Cut-surface (stem) |
Herbicide Application Method
| Herbicide Product Name: |
| Herbicide Common Name (active ingredient): |
| Surfactant Product Name: |
Water Source Used
Comments/remarks (include information such as encounters with people, equipment issues, unusual conditions, etc.
| _ | _ | ___________________ | |||
| Contractor’s Signature | COR/GTM’s Signature: | _______ |
Work Items – Note: record calculated numbers to two decimal places.
| A |
| B |
| C |
| D |
| E |
| F |
| G |
| Area – Map Label |
| NNIP Species Treated |
| Amount Treated - acres |
| Start Time Military: HHMM |
| Stop Time Military HHMM |
| Volume of Water (Gals) |
| Volume of Water (Ounces) |
| Glyphosate (Ounces) |
| Total Volume |
Ounces (B+C+F) Herbicide Percent Solution _C_ X 100% D Surfactant (Ounces) Surfactant Percent Solution _F_ X 100% D
| Acres |
| Area in Square Feet |
| Approximate Length X Width |
| 1 |
| 43,560 |
| 208.8’ x 208.8’ |
| 0.5 |
| 21,780 |
| 147.6’ x 147.6’ |
| 0.1 |
| 4,356 |
| 66’ x 66’ |
| 0.01 |
| 435 |
| 20.9’ x 20.9’ |
| 0.001 |
| 44 |
| 6.6’ x 6.6’ |
Conversion Factors 1gallon = 128 ounces 1quart = 32 ounce
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