W911SA-22-Q-3013 Attachment 4 Contracted Pest Management Record.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@mail.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-rd.mbx.integrated-pest-management@mail.mil
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