A06_Blank pesticide application record.doc

Bureau of land Management Pesticide Application Record edited: 3/25/2020 1.

a. Project Name: __________________________________________

b. Operator: ____________________________________________

c. PUP number: ________________

2. Name of Employee(s) Applying the Pesticide: _________________________

3. Date(s) of Application: _

4. Time Frame of Application: _______________________________________

5. Location of Application: T._____________ R.___________ Sec.__________

County: ________________________________________

6. Type of Equipment used: _________________________________________

7. Pesticide(s) Used:

a. Trade Name: _________________________________________________ i.e. Plateau

b. Active Ingredient: _____________________________________________ i.e. Imazapic

c. EPA Number: ________________________________________________ i.e. 241-365

8. Rate of Application: (% Solution if spot application)

a. Active Ingredient per Acre: __________________________________i.e. 0.089 lbs/acre

b. Volume of Pesticide per Acre (Trade Name): _____________________ i.e. 6 oz/acre

c. Total Pesticide Used (Trade Name): ___________________________i.e. 1842 oz Plateau

d. Total Active Ingredient Used:___________________________i.e. 27.2 lb A.I. Imazapic

9. Area Treated:

a. Actual Area Treated: _ i.e. 307 acres

b. Total Project Area: _____

c. Total Gallons Used: _________________________________

10. Primary Pests Involved: ____________________________________________________________________________________________________________________________________________________________

11. Stage of Pest Development: _______________________________________________

12. Weather Conditions:

a. Wind Direction: _________________

b. Wind Velocity: ___________________________________

c. Temperature: _____________________________________ NISIMS (For BLM office use):

Map name: ________________________________________________________________ File location: _______________________________________________________________

*This record is required and must be completed for monitoring within 24 hours after completion of application of pesticides. This record must be maintained for a minimum of 10 years.