W911SA-19-Q-3011_Attachment_6_-_Sample_Service_Ticket.pdf

* A separate form will be filled our for EACH pest management operation.

* Before application of pesticide, check 63d RSC Approved Contracted Pest Management Materials List (see below)

* Emails COMPLETED copy to: 63d RSC, Environmental Branch

2. Facility Name/ID (If unknown ask facility personnel):

Indoor Outdoor

3. Type of Pest Control Operation (Choose ONE):

Baiting Set/Service Traps Manual Application Power Spray (Truck Mounted) Surveillance Other (explain):

Housing Office/Admin Area Lawn Unimproved Grounds (rocks,dirt, and open field areas) Warehouse Sewer/Storm drains

Other (explain):

5. Target Pest (DO NOT WRITE "GENERAL"):

6. Total Area Treated (choose from below & complete actual area) SF(square Feet AC (acre) EA (total number of bait stations/traps)

7. Pesticide Information:

Aerosol Bait Dust/Granule Solution Solution Suspension Emulsion

4. Site description (Choose ALL that apply):

Vehicle/Equipment Maintenance Shop

Pesticide Trade Name:

Pesticide Active Ingredient:

63D RSC

Contracted Pest Management Record

1. Date of Application (MM/DD/YYYY):

EPA REG #:

Formulation (choose below):

CPMR - Con't

FACID:

Application Date

FL (fluid ounce) LB (pound) GA (gallon) DR (dry ounce)

GR (gram)

8. Comments (survey hours and results, wind conditions, sanitation deficiencies, etc…):

9. Signature of Applicator:

Certification/License number:

expiration date:

10. Company:

11. 63d RSC Environmental Approval:

(date)

(printed name) address phone

(printed name)

Quantity of pesticide CONCENTRATE applied:

Percentage of Active Ingredient per lable (%):