W911SA-20-Q-3005_(Attachment_5_-_88th_RD_UPMARF).pdf

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)____________