W911SA-18-Q-3036_Attachment_4_Grounds_Weed_Control_Form_V_1.4_(14_MAY_2018).docx

88th RD

WEED CONTROL RECORD FORM

Version 1.4; 14 May 2018 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): ___________________