W911SA-23-Q-3021 Attachment 5 - UT007 Grounds Pest Management Form.docx

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Attached to
Grounds, UT007 (49676) West Ogden, Utah Federal contract opportunity
Solicitation number
W911SA-23-Q-3021
Issued by
Department of the Army Materiel Command Mission and Installation Contracting Command Fort McCoy

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Other files attached to Grounds, UT007 (49676) West Ogden, Utah, newest first.
File Type Posted
W911SA-23-Q-3021 UT007 Grounds Solicitaion.pdf PDF
W911SA-23-Q-3021 Attachment 2 - UT007 Grounds Drawing.pdf PDF
W911SA-23-Q-3021 Attachment 3 - UT007 GROUNDS AT_OPSEC.pdf PDF
W911SA-23-Q-3021 Attachment 4 - UT007 Grounds Sample Service Ticket.docx DOCX document
W911SA-23-Q-3021 Attachment 1 - UT007 Grounds Price Schedule_CUI.xlsx XLSX spreadsheet

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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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