Tech Exhibit 4 - Pesticide Application Record.pdf

PESTICIDE APPLICATION RECORD SHEET

Corps of Engineers, Omaha District

ER 1130-2-540 FIELD OFFICE: DATE:

PREPARED BY: PHONE: ( )

Check one: ANTICIPATED USAGE REQUEST

ACTUAL USAGE REPORT

COMPLETE THIS SECTION FOR BOTH ANTICIPATED USAGE REQUEST AND FOR AN ACTUAL USAGE

REPORT

TARGET PEST:

SPECIFIC DESCRIPTION OF SITE(S):

PESTICIDE TRADE NAME:

MANUFACTURER:

EPA REGISTRATION NO:

EPA CLASS: GENERAL FORMULATION: LIQUID

RESTRICTED GRANULAR

PESTICIDE MIXTURE:

(if applicable) (i.e. 1 gallon/50 gallons water)

APPLICATION RATE:

(i.e. gals./sq.ft. or lbs./acre)

NUMBER & TIMING OF APPLICATIONS:

USE THIS SECTION FOR ACTUAL USAGE REPORT ONLY

DATE PESTICIDE WAS APPLIED: TIME:

APPLICATION EQUIPMENT &

METHOD OF APPLICATION:

APPLIED BY: Corps employee Contractor

NAME OF APPLICATOR:

ADDRESS:

(if contractor)

PHONE:

TOTAL AREA OF BUILDINGS TREATED:

TOTAL AMOUNT OF PESTICIDE USED:

FOR OUTSIDE APPLICATIONS:

WIND: Calm WIND DIRECTION:

0-10 mph TEMPERATURE:

10-20 mph HUMIDITY:

Other> SOIL: wet moist dry

CEMVR FORM 55-E, 01 Aug 00 (Revised) Previous editions of this form are obsolete