W911SA-24-Q-3091 7.5 Attachment 5 - Pest Management Record.pdf
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- Solicitation number
- W911SA24Q3091
About this file
This document is a Pest Management Record form for use in the 63d Readiness Division's contracted pest management services. The form must be completed for each type of pesticide application and includes details such as the date, location, type of pest control, site description, target pest, total area treated, applicator information, pesticide details (name, EPA registration number, formulation, quantity applied, concentration), facility name and ID, and approvals.
The related federal contract opportunity is a request for quotes for Pest Control Services across multiple locations in Texas, with the Department of the Army Materiel Command Mission and Installation Contracting Command Fort McCoy as the procuring agency. The solicitation number is W911SA24Q3091.
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Text version
63d Readiness Division Contracted Pest Management Record
01OCT2020
Email COMPLETED copy to: 63d RD, Environmental Division:
usarmy.usarc.63-rsc.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-rsc.mbx.integrated-pest-management@mail.mil
File details come from the government source that posted it. Updated .