W911SA-22-Q-3067 Attachment 5 - 88th RD Universal Pest Management Application Reporting Form.docx
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- Solicitation number
- W911SA-22-Q-3067
About this file
This solicitation is for grounds maintenance services at nine locations in Wisconsin. The performance period is from 1 September 2022 to 31 January 2023 with four option years and a six month option to extend services. Quotes are due by the date and time listed in the solicitation and shall be emailed to Christopher.m.brown67.civ@army.mil. The contractor must provide all required documents including a completed SF 1449, information from the supplemental information section, completed price schedule attachment, and signed amendments (if applicable) with their quote submission for it to be considered for award. The solicitation documentation can be accessed at www.sam.gov and vendors will not be directly notified of amendments. The federal agency is the Department of the Army Materiel Command Mission and Installation Contracting Command Fort McCoy.
The attached form is a universal pest management application reporting form to be filled out for each pest management operation conducted. It requests details of the date, location, type of pest control operation, site description, pest, area treated, applicator name, pesticide/herbicide used including trade name, active ingredient, EPA registration number, formulation, quantity applied, and final concentration applied. Signature of the applicator and their certification number are also required. A copy of the completed form must be sent to the 88th PMC on the date indicated in field 12.
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Text version
88th Readiness Division
UNIVERSAL PEST MANAGEMENT APPLICATION REPORTING FORM
A separate form shall be filled out for each pest management operation.
Please print for number 1-9.
1. Date of Application: _________________________
2. Location: 2a. Inside or Outside (circle one) 2b. Facility name and/or building #: _______________________________________
3. Type of Pest Control Operation: ______________________________________________ (e.g., baiting, power spray, ULV, manual application of pesticide etc.)
4. Site Description: ______________________________________ (e.g., office, lawn, unimproved ground, fence line, parking lot cracks, etc.)
5. Pest: _________________________________________(rodents, spiders, nates, weeds, etc.)
6. Area Treated: _________________________________ [Include unit, SF (square feet), LF (linear feet), AC (acre), CF (cubic feet), EA (each - for baiting only)]
7. Applicator’s Name: ___________________________________
8. Pesticide/Herbicide Used:
8a. Pesticide/Herbicide Trade Name: _______________________________________ 8b. Pesticide/Herbicide Active Ingredient: ___________________________________ 8c. EPA or Country Reg #: ________________________________________________ 8d. Formulation: _________________________________________________________ 8d. Quantity of pesticide applied: ___________________________________________ [include unit, FL (fluid ounce), GA (gallon), ML (milliliter), LT (liter), LB (pound), DR (dry ounce), GR (gram), KG (kilogram)] 8e. Final Concentration Applied: _______________________________________ (amount of active ingredient per acre/area)
9. Comments: (survey results, wind conditions, sanitation deficiencies, etc.)
10. Signature of Applicator: ____________________________________________
11. Certification # of Applicator: _________________________________________
12. Copy sent to 88th PMC on (date)____________
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