Exhibit_C,_Attachment_1,_Contractor_Pesticide_Usage_Form.pdf
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- Solicitation number
- 2000018448
- Issued by
- Minnesota
About this file
This is a Contractor Pesticide Usage Form instruction document issued by the Minnesota Department of Military Affairs for contractors performing pest management services at Minnesota Army National Guard (MNARNG) facilities. The form must be completed each time a pesticide application is performed and submitted monthly to the MNARNG Integrated Pest Management Coordinator. Contractors must document pesticide applications across various facility types, including ranges and training areas, barracks, buildings, lawn and ornamental areas, forestry areas, and golf courses. Required information includes the applicator's certification number, facility name, service dates, areas treated, product trade names and EPA registration numbers, active ingredient percentages, physical state of products, volumes or weights used, target pests, and whether aerial application was employed. Safety Data Sheets (SDS) must accompany each submission, or contractors may submit custom company application records containing equivalent information.
Special requirements apply to pesticide applications at Arden Hills Army Training Site (AHATS) and St. Paul CST, where aerial applications require an Aerial Spray Statement of Need (ASSON) prior to service and all pesticides must appear on the MNARNG State Pesticide Use List (SPUL). Submissions should be directed to Russell Howard, MNARNG Integrated Pest Management Coordinator, at 15000 Highway 115, Camp Ripley, Little Falls, Minnesota 56345-4173, via mail or email at russell.d.howard7.nfg@army.mil. All pesticide usage tracking is required to comply with Army Regulation AR 200-5 and applicable DoD, Federal, and State of Minnesota regulations, with annual Pounds of Active Ingredient (PAI) calculations maintained for each facility.
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Text version
Minnesota Department of Military Affairs Contractor Pesticide Usage Form
Instructions: This form must be filled out every time a pesticide application is performed at a Minnesota Army National Guard (MNARNG) facility. This information will be used to calculate the annual Pounds of Active Ingredient (PAI) used at each facility as required by Army Regulation AR 200-5, in addition to DoD, Federal, and State of Minnesota regulations. Contractors must submit this form to the MNARNG Integrated Pest Management Coordinator on a monthly basis.
Please attach Safety Data Sheets (SDS) for each pesticide used. Custom company application records are acceptable in lieu of this form provided they contain the same information required by this form. Submit all forms via mail or email to Russell Howard:
Russell Howard MNARNG Integrated Pest Management Coordinator 15000 Hwy 115, Camp Ripley Little Falls, MN 56345-4173
(320) 616-2617 russell.d.howard7.nfg@army.mil
NOTE: Pesticide applications at Arden Hills Army Training Site (AHATS) and St. Paul CST are subjected to additional Federal requirements, as stated below:
1. Aerial pesticide applications at these locations require an Aerial Spray Statement of Need (ASSON). Contact Russell Howard prior to aerial applications to ensure an ASSON is in place.
2. All pesticides used at these locations must be on the MNARNG State Pesticide Use List (SPUL). Contact Russell Howard for the most up-to-date SPUL or if you would like to request a pesticide to be added to the SPUL.
Contractor Company Name: ____________________________________________________________________________________________
Company Address: ____________________________________________________________________________________________________
Point of Contact Name: ____________________________ Phone #: ___________________ Email Address:___________________________
Applicator Certification Number: ________________________________________________________________________________________
Facility Serviced: ______________________________________________________________________________________________________
Date(s) of Service: _____________________________________________________________________________________________________
Area(s) Treated (check all that best apply):
____Ranges & Other Training Areas ____Barracks, Guest Housing, etc. ____Miscellaneous Buildings (offices, warehouses, depot buildings) ____Food Handling Buildings (interior) ____Lawn & Ornamental ____Ground Maintenance, Right-of-Way & Roadsides ____Forestry & Conservation Areas ____Nuisance Wildlife ____Golf Course ____Other (specify):
mailto:russell.d.howard7.nfg@army.mil
Product (Trade) Name
EPA
Registration
Number
Name and Percent of Active Ingredient (per label)
Physical State (liquid, pellets, granules, etc)
Volume or Weight of Undiluted
Product Used
Target Pest(s) Aerial Application?
(Yes/No)
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