W911SA25QA070 Attachment 09 - Universal Pest Management Application Reporting Form.docx
DOCX document 31 KB Posted
- Attached to
- Grounds Maintenance Services for IL177 multi-site in Illinois Federal contract opportunity
- Solicitation number
- W911SA25QA070
About this file
This is a Universal Pest Management Application Reporting Form template that must be completed for each pest management operation under the 88th Readiness Division. The form requires documentation of application details including date, location (interior/exterior), facility information, type of pest control operation, site description, target pest, area treated, and applicator information.
The form requires specific technical details about pesticides/herbicides used, including trade names, active ingredients, EPA registration numbers, formulations, product quantities (with precise unit measurements), final concentration rates, and total active ingredient amounts. The form must be signed by a certified applicator and submitted to the 88th PMC. This form appears to be Attachment 09 to solicitation W911SA25QA070 for Grounds Maintenance Services at three Illinois locations, though the form itself is simply a template for reporting pest management activities and does not contain specific requirements or scope details.
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Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| W911SA25QA070 Solicitation Final.pdf | ||
| W911SA25QA070 Amendment 0001 final.pdf | ||
| W911SA25QA070 Attachment 07 - Sample Service Ticket.docx | DOCX document | |
| W911SA25QA070 Attachment 02 - AT-OPSEC.pdf | ||
| W911SA25QA070 Attachment 05 - Price Schedule_CUI.xlsx | XLSX spreadsheet | |
| W911SA25QA070 Attachment 04 - Deliverables.docx | DOCX document | |
| W911SA25QA070 Attachment 08 - DOD Pesticides List.pdf | ||
| W911SA25QA070 Solicitation Final.pdf | ||
| W911SA25QA070 Attachment 01 - PWS.docx | DOCX document | |
| W911SA25QA070 Attachment 03 - PRS.xlsx | XLSX spreadsheet | |
| W911SA25QA070 Attachment 06 - Drawings.pdf |
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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 .