J-1503020-03 Planned Pesticide Use Sheet (updated).docx

ATTACHMENT J-1503020-03

PLANNED PESTICIDE USE SHEET

USER GUIDE FOR PLANNED PESTICIDE USE SHEET

This is the User Guide for completing the Planned Pesticide Use Sheet that contains:

(1) Instructions for completing the Planned Pesticide Use Sheet

(2) List of Acceptable Terms

(3) Planned Pesticide Use Sheet Blank Form

The Planned Pesticide Use Sheet shall be included as part of the Contractor’s Work Plan (CWP) for Pest Control. One “Planned Pesticide Use Sheet” shall be filled out for each pest that will be controlled with a pesticide. If more than one pesticide is used to control the pest, one sheet shall be filled out for each of the pesticides used per pest. These forms shall be filled out on-line if the on-line reporting system is used. The link to the system is: https://clients.emainc.com/dcs/pestmanagement/PesticideLogon.asp. The regional NAVFAC Professional Pest Management Consultant should be contacted to obtain a password and instructions to use the system. A new Planned Pesticide Use Sheet shall be filled out whenever pesticides used to control a pest are added or changed.

The List of Acceptable Terms shall be used to complete the Planned Pesticide Use Sheet (see Step 3A). Completed Planned Pesticide Use Sheets shall be attached to the CWP.

ATTACHMENT J-1503020-03

PLANNED PESTICIDE USE SHEET (cont’d)

INSTRUCTIONS FOR COMPLETING THE PLANNED PESTICIDE USE SHEET

The following is a list of instructions for filling out each line of information required on the Planned Pesticide Use Sheet:

1. INSTALLATION, UIC - Insert the name and Unit Identification Code for the installation. The UIC is a five-digit number preceded by an “N" for Navy installations and an “M” for Marine Corps installations. The UIC is available from the KO.

2. APPLICATOR: Insert the name of the individual(s) who will be applying the pesticide.

3. OBJECTIVE

A. TARGET PEST - The name of the pest or pests identified for control. Select the proper pest or pest category from the List of Acceptable Terms.

B. PURPOSE - Explaining the major reason(s) for controlling the target pest(s) Refer to the List of Acceptable Terms.

4. PESTICIDE

A. TRADE NAME – Insert the manufacturer’s name given to the product, e.g., TermidorTM and MaxforceTM , both trade names for fipronil.

B. COMMON NAME - Insert the common or popular name (as opposed to the chemical name).

C. EPA REGISTRATION NUMBER – Insert the number usually found on the front of the label and on the container.

D. FORMULATION – Insert the form that the pesticide is in when ready for use. Refer to the List of Acceptable Terms.

E. CONC ACTIVE INGREDIENT - Insert the percent active ingredient of the pesticide before it is mixed with a diluent. This information should be on the front of the label.

5. APPLICATION

A. USE % - Insert the percent final concentration of the pesticide to be applied.

B. DILUENT – Insert the liquid that is used to dilute the pesticide, e.g., water, oil. If undiluted, indicate, "None".

C. RATE – Insert the quantity of pesticide that will be applied per unit of measure, e.g., 4 pounds per acre; 1 bait per 10 linear feet; 2 gallons per 100 square feet; 2 ounces per minute.

D. METHOD – Insert the method of application, e.g., by hand, power sprayer, ULV generator, compressed air sprayer.

ATTACHMENT J-1503020-03

INSTRUCTIONS FOR COMPLETING THE PLANNED PESTICIDE USE SHEET

E. UNITS TREATED – Identify total quantity treated, e.g., total acres, square feet, linear feet if known. Insert "Varies" if not a definite quantity.

F. SITE – Identify the specific site where the pesticide will be applied. Refer to the List of Acceptable Terms.

G. MONTHS – Insert the time period during which the pest control work will be performed, e.g., a specific month(s), season, or year-round.

6. SENSITIVE AREAS – Identify areas to be avoided or where special caution should be taken. Refer to the “Caution and Warning” statements on the label.

7. INSPECTION METHODS - Identify the method and frequency of inspections, e.g., a cockroach inspection includes the monthly use of a flashlight, a flushing agent and roach sticky traps, or, an inspection for mole crickets on the golf course includes a walk-through evaluation every 3 days.

8. OTHER CONTROLS – Identify other pesticides or methods of control that are used to control the particular pest, e.g., biological control, mechanical control, preventive measures.

9. REMARKS – Include any additional pertinent information If a general pest category has been listed under Target Pest, the specific pests should be listed here. Planned Pesticide Use Sheets MUST be turned in to the Performance Assessment Representative (PAR) on a weekly basis for the previous week’s treatments.

10. SIGNATURE – A printed name and signature are required on all Planned Pesticide Usage Sheets.

The following people are the only personnel authorized to sign planned pesticide usage sheets:

· Exchanges, clubs, and snack bars – On Duty Manager

· Mess Halls – On Duty Manager

· Schools – Front Office Staff

· CDC’s / Fisher House – Office Staff (Not care providers)

· Fire Departments – Duty Fire Chief, Assistant Chief or Captain of each station

· Range Towers – Since the towers are not manned, the yellow copy must be left in the tower. Range control must be called at 910-451-1410 prior to entering the areas where each tower in located to let Range Control know the technician will be there and the technician will then have to call then when the technician leaves.

ATTACHMENT J-1503020-03

LIST OF ACCEPTABLE TERMS FOR PLANNED PESTICIDE USE SHEETS

ATTACHMENT J-1503020-03

LIST OF ACCEPTABLE TERMS FOR PLANNED PESTICIDE USE SHEETS (cont’d)

FORMULATION

FLOWABLE POWDER

FOOD STORAGE AREAS

ATTACHMENT J-1503020-03

BLANK FORM

INSTALATION NAME: _______________________________________________

UIC: _______________________________________________________________

APPLICATOR: _______________________________________________________

TARGET PEST: _______________________________________________________

PURPOSE: __________________________________________________________

TRADE NAME: ______________________________________________________

COMMON NAME: ___________________________________________________

EPA REG NO: _______________________________________________________

FORMULATION: _____________________________________________________

CONC AI: ___________________________________________________________

USE%: _____________________________________________________________

DILUTENT: _________________________________________________________

RATE: _____________________________________________________________

METHOD: ____________________________________________________________

UNITS TREATED: ____________________________________________________

SITE: ______________________________________________________________

DATE: _____________________________________________________________

SENSITIVE AREAS: ___________________________________________________

INSPECTION METHODS: ______________________________________________

OTHER CONTROLS: __________________________________________________

REMARKS: _________________________________________________________

SITE POINT OF CONTACT (PRINT): ______________________________________

SITE POINT OF CONTACT (SIGNATURE): _________________________________