Pesticide Application Record.pdf

Pesticide Management Division PO Box 42560

Olympia WA 98504-2560 Phone: (877) 301-4555

AGR-4226 (R/8/19) Page 1 of 3

Pesticide Application Record (Version 1 — Single Application) This form must be completed the same day as the application and it must be retained for 7 years. (Chapter 17.21 RCW)

1. Date of Application — Year: Month: Day: Start Time:

Stop Time:

2. Name of person for whom the pesticide was applied:

Firm Name (if applicable):

Street Address: City: State: Zip Code:

3. Licensed Applicator's Name (if different from #2 above): License Number:

Firm Name (if applicable): Phone Number:

Street Address: City: State: Zip Code:

4. Name of person(s) who applied the pesticide (if different from #3 above):

License Number(s) (if applicable):

5. Crop or Type of Site:

6. Total Area Treated (acre, square feet, etc.):

7. Was this application made as a result of a WSDA Permit? No Yes — If yes, give Permit Number:

8. Pesticide Information (list all information for each pesticide, including adjuvants (buffer, surfactant, etc.) in the tank mix):

a) Full Product Name b) EPA Registration Number

c) Total Amount of Pesticide Applied in

Area Treated

d) Pesticide Applied / Acre (or other measure)

e) Concentration Applied

9. Address or exact location of application (if the application is made to one acre or more of agricultural land, the field location must be shown on the map on page two of this form):

10. Wind direction and estimated velocity (mph) during the application:

11. Temperature (F°) during the application:

12. Apparatus license plate number (if applicable):

13. Application Method / Type: Air Ground Chemigation

14. Depth of Chemigation Application:

15. Other Information:

http://app.leg.wa.gov/rcw/default.aspx?cite=17.21

AGR-4226 (R/8/19) Page 2 of 3

Location of Application If the application covers more than one township or range, please indicate the township & range for the top left section of the map only.

Township: N

Range: E W (please indicate)

Section(s):

Block: Farm Unit:

or GPS:

County:

PLEASE NOTE: The map is divided into 4 sections with each section divided into quarter-quarter sections. Please complete it by marking the appropriate section number(s) on the map and indicate as accurately as possible the location of the area treated.

Section: Section:

One Mile

N

Section: Section:

Other Information:

AGR-4226 (R/8/19) Page 3 of 3

INSTRUCTIONS

Pesticide Application Record (Version 1 — Single Application)

1. Date may be spelled out or indicated numerically. Time must be indicated as start and stop times.

2. Include complete first and last name.

3. If the person's name is the same as Number 2, write "same" in the space for the licensed applicator's name and include the license number (if applicable) and phone number.

4. Include complete first and last name(s).

5. Indicate type of land (crop) or site treated, not location. (Examples: Wheat, apples, rights-of-way, lawn, trees and shrubs, crawl space, wall voids, etc.)

6. Total Area treated may also be stated in terms such as linear feet, cubic feet, etc. Specify the term to which the number refers. If spot treatment, write spot treatment.

7. If the application was made under permit, but no permit number was issued, indicate the date the permit was issued.

8. a) Brand name found on the pesticide label. If the material is an adjuvant (buffer, spreader, sticker, surfactant, etc.), write in brand name found on the product's label.

b) EPA Registration Number found on the pesticide container label. If the material is being applied under a federal experimental use permit and no EPA Registration Number exists, list the federal experimental use permit number. If an adjuvant (buffer, spreader, sticker, surfactant, etc.), write in the state registration number.

c) Indicate the amount of pesticide formulation (product) applied to the total area listed on line 6.

d) Other measures may include amount / square feet, amount / cubic feet, amount / linear feet, etc.

e) Concentration may be listed in various ways, such as: Amount of product / 100 gallons water, percent formulation in the tank mix (i.e., 1%), gallons per acre of output volume (i.e., GPA), ppm (or other measure), or inches of water applied (chemigation). Specify the term to which the number refers.

9. Agricultural land includes such areas as forest lands and range lands. It does not include transportation and utility rights-of-way.

10. Indicate the direction from which the wind is blowing. Measure wind velocity in MPH. If the wind varies in direction and velocity during the application, indicate the range of variance (e.g., S-SW 3-7 MPH). Wind readings shall be obtained in close proximity to the application site.

11. Indicate temperature in degrees Fahrenheit (it may be indicated as the range encountered during application). Temperature readings shall be obtained in close proximity to the application site.

12. Only for Commercial Application businesses.

13. Check one.

14. Depth of application / inches of water (chemigation).

15. This space is available for any additional information you may wish to include.

OTHER_INFO: