W911SA25QA071 Attachment 08 - Universal Pest Management Application Reporting Form.pdf
PDF 3 MB Posted
- Solicitation number
- W911SA25QA071
About this file
This is a Universal Pest Management Application Reporting Form template used by the 88th Readiness Division, with an example completed form shown. The form requires detailed documentation of pest management operations, including date, location (indoor/outdoor), facility information, type of pest control operation, site description, target pest, and area treated using specific measurement units (square feet, linear feet, acres, etc.).
The form demands comprehensive pesticide/herbicide application details including trade name, active ingredients, EPA registration number, formulation percentages, amount used, final concentration, and total active ingredient applied. The example shows an outdoor application of Roundup Power Max (glyphosate) at Tract 2 in Des Moines, IA, treating 150 acres of alfalfa field for broad leaves on 6/23/22. The applicator used 37.5 gallons of product mixed with 1245 gallons of water, achieving a final concentration of 15.58 fl oz/AC, with weather conditions and application times documented. This form appears to be an attachment to a grounds maintenance services solicitation (W911SA25QA071) for the Department of the Army.
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Other files
| File | Type | Posted |
|---|---|---|
| W911SA25QA071 Amendment 0001 Final.pdf | ||
| W911SA25QA071 Solicitation Final.pdf | ||
| W911SA25QA071 Attachment 02 - AT-OPSEC.pdf | ||
| W911SA25QA071 Attachment 06 - Drawing.pdf | ||
| W911SA25QA071 Attachment 01 - PWS.docx | DOCX document | |
| W911SA25QA071 Attachment 07 - Sample Service Ticket.docx | DOCX document | |
| W911SA25QA071 Attachment 04 - Deliverables.docx | DOCX document | |
| W911SA25QA071 Attachment 05 - Price Schedule_CUI.xlsx | XLSX spreadsheet | |
| W911SA25QA071 Attachment 03 - PRS.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 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 .