Attachment 5 - W911SA25QA041 88th RD Universal Pest Management Application Reporting Form.docx
DOCX document 31 KB Posted
- Attached to
- Grounds Maintenance Services at KS085 Leavenworth, KS Federal contract opportunity
- Solicitation number
- W911SA25QA041
About this file
This is a Universal Pest Management Application Reporting Form template that must be completed for each pest management operation under contract W911SA25QA041 for the 88th Readiness Division. The form requires detailed documentation of pest control activities including the date, location (indoor/outdoor), facility information, type of pest control operation, site description, target pest, area treated (with specific units), applicator information, and comprehensive pesticide/herbicide details such as trade name, active ingredients, EPA registration, formulation percentages, amount used, final concentration, and total active ingredients applied. The form also requires the applicator's signature, certification number, and confirmation that a copy was sent to the 88th PMC.
This form is an attachment to a broader grounds maintenance services solicitation (W911SA25QA041) for one location in Leavenworth, Kansas, with a performance period from March 1, 2025, to February 28, 2026, plus four option years and a six-month extension option. The solicitation will be issued January 16, 2025, with questions due by January 22, 2025, at 10:00 AM CST. The contract will be administered by the Department of the Army Materiel Command Mission and Installation Contracting Command at Fort McCoy.
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Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| W911SA25QA041 Wage Determination Log.xlsx | XLSX spreadsheet | |
| W911SA25QA041 Grounds PRS.xlsx | XLSX spreadsheet | |
| Attachment 1 - W911SA25QA041 Price Schedule - CUI.xlsx | XLSX spreadsheet | |
| Attachment 3 - W911SA25QA041 KS085 Grounds Drawing.pdf | ||
| Attachment 4 - W911SA25QA041 Sample Service Ticket.docx | DOCX document | |
| Attachment 6 - W911SA25QA041 DOD Pesticides List.pdf | ||
| Attachment 2 - W911SA25QA041 AT-OPSEC.pdf | ||
| W911SA25QA041 Solicitation.pdf | ||
| W911SA25QA041 KS085 Grounds PWS.docx | DOCX document | |
| W911SA25QA041 Grounds Deliverables.docx | DOCX document | |
| W911SA25QA021 Wage Determination Log.xlsx | XLSX spreadsheet |
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Text version
88th Readiness Division
UNIVERSAL PEST MANAGEMENT APPLICATION REPORTING FORM
A separate form shall be filled out for each pest management operation.
Please print for number 1-9.
1. Date of Application: _________________________
2. Location: 2a. Inside or Outside (circle one) 2b. Facility name and/or building #: _______________________________________
3. Type of Pest Control Operation: ______________________________________________ (e.g., baiting, power spray, ULV, manual application of pesticide etc.)
4. Site Description: ______________________________________ (e.g., office, lawn, unimproved ground, fence line, parking lot cracks, etc.)
5. Pest: _________________________________________(rodents, spiders, nates, weeds, etc.)
6. Area Treated: _________________________________ [Include unit, SF (square feet), LF (linear feet), AC (acre), CF (cubic feet), EA (each - for baiting only)]
7. Applicator’s Name: ___________________________________
8. Pesticide/Herbicide Used:
8a. Pesticide/Herbicide Trade Name: _______________________________________ 8b. Pesticide/Herbicide Active Ingredient: ___________________________________ 8c. EPA or Country Reg #: ________________________________________________ 8d. Formulation: _________________________________(percentage of AI from label) 8e. Amount of Product Used: ___________________________________________ [include unit, FL (fluid ounce), GA (gallon), ML (milliliter), LT (liter), LB (pound), DR (dry ounce), GR (gram), KG (kilogram) AND how much water was added] 8f. Final Concentration Applied: _______________________________________ [amount of ACTIVE INGREDIENT (AI) per area (examples: 1.5 oz/gal, 4lbs/1000 SF] 8g. Total Amount of Active Ingredient applied in this pest management operation: ___________________________________ [in fl oz (if liquid) or weight (if solid)]
9. Comments: (survey results, wind conditions, sanitation deficiencies, etc.)
10. Signature of Applicator: ____________________________________________
11. Certification # of Applicator: _________________________________________
12. Copy sent to 88th PMC on (date)____________
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