Exhibit_C,_Attachment_1,_Contractor_Pesticide_Usage_Form.pdf
PDF 140 KB Posted
- Solicitation number
- 2000018461
- Issued by
- Minnesota
About this file
This is a Contractor Pesticide Usage Form issued by the Minnesota Department of Military Affairs for the Minnesota Army National Guard (MNARNG). The form must be completed by contractors each time a pesticide application is performed at any MNARNG facility throughout Minnesota. Contractors are required to submit the form monthly to Russell Howard, the MNARNG Integrated Pest Management Coordinator, along with Safety Data Sheets (SDS) for each pesticide used, or acceptable alternative company application records containing equivalent information. The form requires contractors to document facility serviced, dates of service, areas treated (including ranges, barracks, buildings, lawns, grounds maintenance, forestry areas, and golf courses), specific pesticide products with EPA registration numbers, active ingredient percentages, application volumes or weights, target pests, and whether aerial application was used. Submissions should be directed to Russell Howard at 15000 Hwy 115, Camp Ripley, Little Falls, MN 56345-4173, by phone at (320) 616-2617, or by email at russell.d.howard7.nfg@army.mil.
Pesticide applications at Arden Hills Army Training Site (AHATS) and St. Paul CST are subject to additional federal requirements. Aerial pesticide applications at these locations require an Aerial Spray Statement of Need (ASSON) to be in place prior to application, which must be coordinated with Russell Howard. All pesticides used at AHATS and St. Paul CST must be approved on the MNARNG State Pesticide Use List (SPUL); contractors seeking to use pesticides not currently on the SPUL must request approval from Russell Howard. The form collects data to calculate annual Pounds of Active Ingredient (PAI) used at each facility as mandated by Army Regulation AR 200-5 and applicable DoD, federal, and State of Minnesota regulations.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| Addendum_2.pdf | ||
| Attachments_and_Declarations_18461_REISSUE.pdf | ||
| REISSUE__Lawn_Care_at_Mult_MN_Nat_l_Guard_Armories.pdf | ||
| Sample_Contract_and_Exhibits_18461_REISSUE.pdf | ||
| Exhibit_E_-_Lawn_Care_Maintenance_and_Services_Report.xlsx | XLSX spreadsheet | |
| Exhibit_C,_Attachment_3,_Facility_Maps_by_Location.pdf | ||
| Exhibit_D_-_Price_Schedule_18461_REISSUE.xlsx | XLSX spreadsheet | |
| Exhibit_C,_Attachment_2,_Ground_Care_Tasks.xlsx | XLSX spreadsheet | |
| Request_for_Proposal_18461_REISSUE.pdf | ||
| Exhibit_C,_Attachment_3,_Facility_Maps_by_Location.pdf.crdownload | CRDOWNLOAD file |
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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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