W911SA25QA007 - Attachment 9 - 88th RD Universal Pest Management Application Reporting Form V 2.2 Example.pdf
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- W911SA-25-Q-A007
About this file
This is a Universal Pest Management Application Reporting Form template from the 88th Readiness Division, with an included example of a completed form. The form requires detailed documentation of pest control operations, including application date, location (indoor/outdoor), facility details, type of pest control operation, site description, target pest, area treated, and comprehensive pesticide/herbicide information.
The example form shows a pest management operation conducted on 6/23/22 at Tract 2 in Des Moines, IA, involving a power spray application of Roundup Power Max (glyphosate) to control broad leaves in an alfalfa field. The application covered 150 acres, using 37.5 gallons of product mixed with 1245 gallons of water, resulting in a final concentration of 12GA/AC = 15.58 fl oz/AC. The total active ingredient applied was 18.26 GA AI, with the operation conducted between 3:30 PM and 5:15 PM under 4 mph southwest winds. The form requires applicator certification details and submission to the 88th PMC.
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Text version
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 City/State: _______________________________________
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 SF (sq ft), LF (linear ft), AC (acre), CF (cubic ft), 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: _________________________________(percentage of AI from label) 8e. Amount of Product Used: ___________________________________________ [include unit, e.g., FL (fluid ounce), GA (gallon), ML (milliliter), LT (liter), LB (pound), DR (dry ounce), GR (gram), KG (kilogram) AND how much water was added] 8f. Final Concentration Applied: _______________________________________ [amount of ACTIVE INGREDIENT (AI) per area (examples: 1.5 oz/gal, 4lbs/1000 SF] 8g. Total Amount of Active Ingredient applied in this pest management operation:
___________________________________ [in fl oz (if liquid) or weight (if solid)]
9. Comments: (survey results, wind conditions, sanitation deficiencies, etc.)
10. Signature of Applicator: ____________________________________________
11. Certification # and Expiration Date of Applicator: _______________________________
12. Copy sent to 88th PMC on (date)___________________
| 88th RD Universal Pest Management Application Reporting Form V1.6 (3OCT2022) and EXAMPLE KJC 4 Oct 2022 |
| 88th RD Universal Pest Management Application Reporting Form V1.5 (18 JAN 2019) KJC 3 Oct 2022 |
Example Pesticide Use Form
File details come from the government source that posted it. Updated .