W911SA25QA034 Attachment 09 - Universal Pest Management Application Reporting Form.docx
DOCX document 31 KB Posted
- Attached to
- Grounds Maintenance MN076 (MS)
- Solicitation number
- W911SA25QA034
About this file
This is a Universal Pest Management Application Reporting Form template that must be completed for each pest management operation under the Grounds Maintenance contract at the 88th Readiness Division. The form requires detailed documentation of pest control activities including the date, location (indoor/outdoor), facility details, type of pest control operation, site description, target pest, and area treated measurements (in square feet, linear feet, acres, etc.).
The form mandates recording specific pesticide/herbicide information including trade names, active ingredients, EPA registration numbers, formulations, amount of product used (with precise unit measurements), final concentration applied, and total amount of active ingredient used. Additional requirements include the applicator's name, certification number, signature, and documentation of when the copy was sent to the 88th PMC. The form also includes a section for comments regarding survey results, wind conditions, and sanitation issues.
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Other files
| File | Type | Posted |
|---|---|---|
| W911SA25QA034 Attachment 06 - Price Schedule - CUI.xlsx | XLSX spreadsheet | |
| W911SA25QA034 Attachment 02 - AT-OPSEC.pdf | ||
| W911SA25QA034 Solicitation.pdf | ||
| W911SA25QA034 Attachment 03 - PRS.xlsx | XLSX spreadsheet | |
| W911SA25QA034 Attachment 04 - Deliverables.docx | DOCX document | |
| W911SA25QA034 Attachment 01 - PWS.docx | DOCX document | |
| W911SA25QA034 Attachment 08 - Service Ticket.docx | DOCX document | |
| W911SA25QA034 Attachment 07 - Drawings.pdf | ||
| W911SA25QA034 Attachment 10 - DOD Pesticides List.pdf | ||
| W911SA25QA034 Attachment 05 - Wage Determination Log.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 .