W911SA25QA026 Attachment 09 88th RD Universal Pest Management Application Reporting Form.docx
DOCX document 31 KB Posted
- Solicitation number
- W911SA25QA026
About this file
This file is a Universal Pest Management Application Reporting Form template used by the 88th Readiness Division for documenting pest control operations. The form requires detailed documentation of each pest management operation, including the date, location (indoor/outdoor), facility details, type of pest control operation, site description, target pest, area treated, applicator information, and comprehensive pesticide/herbicide details. The pesticide section requires specific information about trade names, active ingredients, EPA registration numbers, formulations, product amounts used, final concentration applied, and total active ingredient quantities.
This form template is associated with solicitation W911SA25QA026 for grounds maintenance services at facility IN085 in Michigan City, IN, issued by the Department of the Army Mission and Installation Contracting Command at Fort McCoy. The contract period is from April 1, 2025 to March 31, 2026, with four 12-month option years. Quotes are to be submitted via email to leslie.a.koenig2.civ@army.mil, with written questions due by February 24, 2025, at 10:00 A.M. CST. No site visit is scheduled for this solicitation.
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Other files
| File | Type | Posted |
|---|---|---|
| W911SA25QA026 Attachment 02 AT-OPSEC.pdf | ||
| W911SA25QA026 Attachment 01 PWS.docx | DOCX document | |
| W911SA25QA026 Attachment 05 Wage Determination Log.xlsx | XLSX spreadsheet | |
| W911SA25QA026 Attachment 07 Drawing.pdf | ||
| W911SA25QA026 Attachment 08 Sample Service Ticket.docx | DOCX document | |
| W911SA25QA026 Solicitation.pdf | ||
| W911SA25QA026 Attachment 03 PRS.xlsx | XLSX spreadsheet | |
| W911SA25QA026 Attachment 04 Deliverables.docx | DOCX document | |
| W911SA25QA026 Attachment 06 Price Schedule CUI.xlsx | XLSX spreadsheet |
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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/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: _________________________________(percentage of AI from label) 8e. Amount of Product Used: ___________________________________________ [include unit, 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 # of Applicator: _________________________________________
12. Copy sent to 88th PMC on (date)____________
File details come from the government source that posted it. Updated .