W911SA-22-Q-3012 Attachment 4 Contracted Pest Management Record.pdf

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Attached to
Pest Control Services for Various USAR Facilities in Texas
Solicitation number
W911SA-22-Q-3012
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Other files

File Type Posted
W911SA-22-Q-3012 Solicitation.docx DOCX document
W911SA-22-Q-3012 Attachment 6 Pesticide Use List 63d RD.pdf PDF
W911SA-22-Q-3012 Attachment 2 Pest Services Price Schedule-CUI.xlsx XLSX spreadsheet
W911SA-22-Q-3012 Attachment 5 Integrated Pest Management Plan 63d RD.pdf PDF
W911SA-22-Q-3012 Attachment 7 Wage Determination.docx DOCX document
W911SA-22-Q-3012 Attachment 1 Drawing List.docx DOCX document
W911SA-22-Q-3012 Attachment 3 AT OPSEC 63d RD Pest Control Services.pdf PDF

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63d Readiness Division Contracted Pest Management Record

01OCT2020

Email COMPLETED copy to: 63d RD, Environmental Division:

usarmy.usarc.63-rd.mbx.integrated-pest-management@army.mil

A separate form MUST be filled out for EACH TYPE of pesticide applied.

1. Date of Application: ___________________________________________________________

2. Location (choose ONE): Outside Inside Building #(s):______________________

3. Type of Pest Control (choose ONE):

Baiting Set/Service Traps Manual Application Power Pesticide Application Surveillance Other: __________________________

4. Site Description (choose ONE):

Family Housing Unimproved Grounds Industrial Facilities Warehouse (non-food storage) Lawns Other: __________________________ Office/Administration Areas

5. Target Pest (Do Not Write “General”):_____________________________________________

6. Total Area Treated:

________Acres _________________Square Feet ______Each (total # of bait stations/traps)

7. Applicator Name (printed):______________________________________________________

8. Pesticide Name (REQUIRED): __________________________________________________

9. Percent Active Ingredient % (Per label):___________________________________________

10. EPA Registration (REQUIRED) #: _______________________________________________

11. Formulation:

Aerosol Solution Dust/Granule Emulsion Bait Suspension

12. Total Quantity Applied (REQUIRED):

_________Fluid Ounces ______Gallons ______Pounds ______Dry Ounces ______Grams

13. Final Concentration % (REQUIRED):_____________________________________________

14. Facility Name and Facility ID Number: ____________________________________________

15. Applicator Signature: _________________________________________________________

Applicator License #:_________________________ Expiration Date:_______________

16. Company: __________________________________ Phone: _________________________

Address: ______________________________________________________________

17. 63d RD Approval Signature: ________________________________Date:_______________

Printed Name: __________________________________________________________ mailto:usarmy.usarc.63-rsc.mbx.integrated-pest-management@mail.mil

File details come from the government source that posted it. Updated .