Section J_Technical Exhibit E. Herbicide_Pesticide Report.pdf
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This document is an Applicator Use Records Form template for recording herbicide and pesticide applications for January of any given year. The form is designed to document agricultural and non-agricultural pesticide applications with detailed tracking requirements.
The primary data collection sections include: Place of Application (farm name, address, specific field or land area, and crop treated); Application Date with end time if applicable; Herbicide/Pesticide(s) Applied using brand or trade names or symbols cross-referenced to a chemical code list; EPA Registration Number; Recipe (formulation details); Total Applied (quantity); Application Site(s) using coded site and location combinations; and Applicator Name and Registration Number. The document provides supporting reference materials including a Chemical Code List (13 codes for herbicide/pesticide products with corresponding chemical names and EPA registration numbers), an Application Method Code Examples table (8 methods ranging from high-pressure hydraulic spray to other methods), Site Code Examples table (for identifying tenant, building number, application site, and application location), and a Property Sketch section with fields for front, rear, sides, and total square footage. An additional simplified recording table on page 5 provides a condensed version of the main form with columns for Date Applied, Herbicide/Pesticide Applied, Recipe, Total Applied, Application Site, Application Method, and Applicator Name & Registration Number. The form is dated 02/12/26 and serves as a compliance document for tracking pesticide applications.
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Text version
02/12/26
APPLICATOR USE RECORDS FORM JANUARY 20XX
1. Place Of Application
Application
Date Herbicide/Pesticide(s) Applied
EPA
Reg.
Number Recipe Total
Applied
Application
Site(s) Applicator
Name & Reg.#
(End Time applied if applicable)
1. For agricultural applications, the PLACE OF APPLICATION is the name and address of the farm and the specific field or land area and crop that was treated.
2. The brand or trade name of each herbicide/pesticide used or symbol representing such name, providing the business also keeps a list which clearly correlates the symbol used with full and complete pesticide products names.
CHEMICAL CODE LIST
CODE NO.
HERBICIDE/PESTICIDE
BRAND/TRADE NAME
HERBICIDE/PESTICIDE CHEMICAL
NAME
EPA REG.NUMBER
APPLICATION METHOD CODE EXAMPLES
CODE
NO.
METHOD
APPLICATION METHOD CODE EXAMPLES
CODE
NO. APPLICATION METHOD CODE
NO. APPLICATION METHOD
1. High Pressure Hydraulic Spray 5. Hand Held Sprayer
2. Low Pressure Hydraulic Spray 6. Rotary Spreader
3. Low Pressure Boom Sprayer 7. Drop Spreader
4. Back-Pack Sprayer 8. Other:
SITE CODE EXAMPLES
TENANT BUILDING NUMBER APPLICATION
SITE APPLICATION LOCATION
The site of application would be a combination of the SITE CODE NUMBER and the LOCATION CODE NUMBER. For example: If the cabinets and baseboard in the kitchen and bathrooms were treated the code for the sites of application would be 1AB, 2AB.
SKETCH OF PROPERTY
Front Sq. Ft. = Rear Sq. Ft. = Sides Sq. Ft. = Total Sq. Ft. =
DATE
APPLIED
HERBICIDE/PESTICIDE
APPLIED Recipe Total Applied APPLICATION
SITE
APPLICATION
METHOD
APPLICATOR
NAME & REG.#
SKETCH OF PROPERTY
File details come from the government source that posted it. Updated .