W911SA-17-Q-0068_Attachment_7_Grounds_Weed_Control_Form_V_1.0_(25_OCT_2016).docx

88th RSC

WEED CONTROL RECORD FORM

A separate form shall be filled out for each operation.

Please print for number 1-8.

1. Date of Application: _________________________

2. Facility Name: ____________________________

3. Type of Application: ________________________________________ (e.g., power spray, manual application etc.)

4. Site Description: ______________________________________ (e.g. lawn, unimproved ground, fence line, parking lot cracks, etc.)

5. Size of Area Treated: _________________________________ [Include unit, SF (square feet), LF (linear feet), AC (acre), CF (cubic feet)]

6. Applicator’s Name: ___________________________________

7. Herbicide Used:

7a. Herbicide Trade Name: ___________________________________

7b. Herbicide Active Ingredient: ________________________________________

7c. EPA or State Reg # : ________________________________

7d. Formulation: _____________________________________

7d. Quantity of herbicide applied ____________________________ [(include unit, FL (fluid ounce), GA (gallon), ML (milliliter), LT (liter), LB (pound), DR (dry ounce), GR (gram), KG (kilogram)]

7e. Final Concentration Applied (%): _______________________________

8. Additional Comments: (survey results, wind conditions, sanitation deficiencies, etc.)

9. Signature of Applicator: ___________________________________

10. Certification # of Applicator: _______________________________

11. (PWS #5.3.5) Copy of this form attached to invoice in iRAPT on (date): ___________________ Version 1.0 25 OCT 2016