Technical Exhibit 4_PesticideAppRecordForm.pdf
PDF 76 KB Posted
- Solicitation number
- W9128F23Q0041
About this file
This document contains a pesticide application record sheet template for the Corps of Engineers, Omaha District. The form collects details on anticipated and actual pesticide usage, including the target pest, specific application sites, pesticide trade name and manufacturer, EPA registration number and classification, formulation as liquid or granular, application rate, number and timing of applications, date and time pesticide was applied, application equipment and method, name and contact information of applicator if contracted, total area and amount of pesticide used, and environmental details for outside applications including wind speed and direction, temperature, humidity, and soil conditions. The bottom of the form includes fields to input these details and allows resetting the form.
View the file
Other files
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
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
| FIELD OFFICE: |
| Date: |
| PREPARED BY: |
| Area Code: |
| Prep Phone #: |
| Anticipated Usage: Off |
| Actual Usage: Off |
| TARGET PEST: |
| TARGET PEST 1: |
| SPECIFIC DESCRIPTION OF SITES: |
| Specific Description 1: |
| PESTICIDE TRADE NAME: |
| MANUFACTURER: |
| EPA REGISTRATION NO: |
| General: Off |
| Restricted: Off |
| Liquid: Off |
| Granular: Off |
| PESTICIDE MIXTURE: |
| APPLICATION RATE: |
| NUMBER TIMING OF APPLICATIONS: |
| DATE PESTICIDE WAS APPLIED: |
| TIME: |
| METHOD OF APPLICATION: |
| Corps Employee: Off |
| Contractor: Off |
| NAME OF APPLICATOR: |
| Applicator ADDRESS: |
| Applicator Area Code: |
| Applicator Phone Number: |
| TOTAL AREA OF BUILDINGS TREATED: |
| TOTAL AMOUNT OF PESTICIDE USED: |
| Calm: Off |
| 0-10 mph: Off |
| 10-20 mph: Off |
| WIND DIRECTION: |
| TEMPERATURE: |
| HUMIDITY: |
| Other: Off |
| Soil: Off |
| Wet: Off |
| Moist: Off |
| Dry: Off |
| Reset Form: |
File details come from the government source that posted it. Updated .