B08. Attachment 0018- PESTICIDE RECORDKEEPING FORM.pdf
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- Attached to
- Pest Control Services
- Solicitation number
- W519TC26QA023
About this file
This is a Pesticide Recordkeeping Form template for documenting pesticide applications under the Worker Protection Standard and for state and federally restricted use pesticides. The form serves as an appendix and does not address specific contract products or services.
The form requires documentation of up to seven concurrent pesticide applications, with each application entry capturing detailed information across multiple data fields. Required fields include application date, field or site identification, county location with distance and direction from nearest town, acreage or size treated, crop or commodity type, complete product name, active ingredients, EPA registration number, total amount used, restricted entry interval (REI), time of application, wind speed and direction, equipment type and custom application equipment number if applicable, applicator name, and applicator pesticide license number with signature. Additional fields document distance and direction to susceptible crops within a one-mile radius and address of application. The form includes a separate section for spot check documentation requiring the date of check, name of applicator conducting the check, and observations.
Record retention requirements vary by pesticide type: federally restricted use pesticides must be retained for two years; state restricted use pesticides for three years; and all other pesticides under Worker Protection Standard provisions for thirty days after the restricted entry interval ends. An exception applies to agricultural owners in family farm situations, who are not required to record information for themselves or immediate family members, though records must be kept if any employee is from outside the immediate family.
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ATTACHMENT Q: PESTICIDE RECORDKEEPING FORM FOR THE WORKER PROTECTION STANDARD AND STATE AND FEDERALLY RESTRICTED USE PESTICIDES
Records Required Application # __ Application # __ Application # __ Application #__ Application #__ Application #__ Application #__
Date (Mo/Day/Yr)1,2,3
Field or Site ID1,2,3
County, Distance and Direction from the Nearest Town2
Acres/Size or Number Treated1,2
Crop/Commodity1,2
Complete Product Name1,2,3
Active Ingredient(s)3
EPA Registration Number1,2,3
Total Amount Used1
Restricted Entry Interval (REI)3
Time of Application2,3
Distance & Direction to any susceptible crops within 1 mile radius 2
Wind Speed and Direction2
Type of Equipment Used, Custom Application Equipment Number if applicable2
Name of Applicator1,2
Pesticide License Number of Applicator1
Signature of Applicator
(Sect 4.1.7)
(Sect 4.1.9: Location Description)
(Sect 4.1.10)
Sect 4.1.8)
(Sect 4.1.4)
(Section 4.1.6)
Amount & Percentage of Product
(Sect 4.1.5)
(4.1.11-4.1.12)
(Section 3.2.2 )
(Sect 4.1.13)
(Secti 4.1.14.3)
(Sect 4.1.13 & 4.3.3
(Sect 4.1.3)
(Sect 4.1.2)
9sect 7.3) of Crop/Commodity2
Address of Application
1 Required for Federally Restricted Use Pesticides. These records must be kept for two (2) years.
2 Required for State Restricted Use Pesticides. These records must be kept for two (3) years.
3 Required for ALL PESTICIDES (insecticides, herbicides, fungicides, etc.) under the provisions of the Worker Protection Standard. These records must be kept for thirty (30) days after the end of the restricted entry interval (REI) for the respective pesticide. Exception: Agricultural owners in family farm situations are NOT required to record this information for themselves or members of their immediate family. But the information must be recorded if any employee is from outside the immediate family.
Issued in furtherance of Cooperative Extension work, Acts of May 8 and June 30, 1914, in cooperation with the U.S. Department of Agriculture, Dr. Milo J. Shult, Director of Extension Service, University of Arkansas. The Arkansas Cooperative Extension Service offers its programs to all eligible persons regardless of race, color, national origin, sex, age, or disability, and is an Equal Opportunity Employer.
Revised 2/17/12
(Sect 3.1 and Sect 3.2)
Date of Spot Check:
Name of Applicator conducting spot check:
Observations:
File details come from the government source that posted it. Updated .