AF APPROVAL REQ FOR NON-STANDARD PESTICIDES.pdf
PDF 423 KB Posted
- Attached to
- JBLE Grounds Maintenance FY 24
- Solicitation number
- FA480024R0004
About this file
This document is a request form for approval of non-standard pesticides at Joint Base Langley-Eustis in Fort Eustis, Virginia. The form provides fields for details of the pesticide such as the trade name, EPA registration number, active ingredient, signal word, formulation, container size, and quantity requested. It also includes sections for justification of need and applicator information including name and certification number. The form is to be completed and emailed to the MAJCOM Pest Management Consultant for approval or denial.
The related federal contract opportunity is a solicitation from the Department of the Air Force Air Combat Command for grounds maintenance services at Joint Base Langley-Eustis for fiscal year 2024. The solicitation provides an opportunity for contractors to bid on and be awarded a contract to perform grounds maintenance at the base.
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Text version
REQUEST FOR APPROVAL OF NON-STANDARD PESTICIDE
MAJCOM: INSTALLATION:
POINT OF CONTACT: ACTIVITY:
OFFICE SYMBOL:
DSN:
Commercial:
E-MAIL:
POC SIGNATURE
DATE SIGNED
PESTICIDE INFORMATION
TRADE NAME: EPA#
ACTIVE INGREDIENT: SIGNAL WORD:
FORMULATION: CONTAINER SIZE:
QUANTITY REQUESTED: NSN:
TARGET PEST
SPECIES:
JUSTIFICATION STATEMENT (Provide details as to need):
APPLICATOR INFORMATION
NAME: DOD/STATE CERTIFICATION NUMBER
MAJCOM PEST MANAGEMENT CONSULTANT APPROVAL
APPROVED w/conditions: (one time only, used by date, or indefinitely) NOT APPROVED ( Justification)
MAJCOM CONSULTANT SIGNATURE DATE SIGNED
Please complete and e-mail to:
AFCEC NON-STANDARD PESTICIDE APPROVAL FORM 20191022
Continuation:
AFCEC NON-STANDARD PESTICIDE APPROVAL FORM 20191022
| INSTALLATION: Joint Base Langley-Eustis, Fort Eustis |
| POINT OF CONTACT: Tim Christensen |
| OFFICE SYMBOL: CEIE |
| DSN: |
| Commercial: 757-878-4231 |
| EMAIL: TIMOTHY.CHRISTENSEN.6@US.AF.MIL |
| DATE SIGNED: |
| TRADE NAME: |
| ACTIVE INGREDIENT: |
| FORMULATION: |
| CONTAINER SIZE: |
| QUANTITY REQUESTED: |
| NSN: |
| SPECIES: |
| JUSTIFICATION STATEMENT Provide details as to need: |
| NAMERow1: |
| DODSTATE CERTIFICATION NUMBERRow1: |
| NAMERow2: |
| DODSTATE CERTIFICATION NUMBERRow2: |
| NAMERow3: |
| DODSTATE CERTIFICATION NUMBERRow3: |
| Continuation: |
| MAJCOM: [ACC] |
| EPA REGISTRATION #: |
| SIGNAL WORD: [CAUTION] |
| Check Box18: Off |
| Check Box19: Off |
| Text20: |
| What do you want to do and where?: 733d MSG |
Civil Engineer Squadron Fort Eustis, VA 23604
| MAJCOM E-mail: [mark.breidenbaugh@us.af.mil] |
| DATE: |
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