W911SA25QA072 Attachment 10 - Universal Pest Management Application Reporting Form.docx
DOCX document 31 KB Posted
- Solicitation number
- W911SA25QA072
About this file
This is a universal pest management application reporting form template used by the 88th Readiness Division to document individual pest control operations. The form requires detailed documentation of pest control activities including the date, location (interior/exterior), facility information, type of pest control operation (e.g., baiting, power spray, ULV), site description, target pest, and area treated using specific units of measurement (SF, LF, AC, CF, EA). The form also requires comprehensive pesticide/herbicide information including trade name, active ingredients, EPA registration number, formulation details, amount used with specific unit measurements, final concentration applied, and total active ingredient quantity. Additional requirements include applicator information, certification numbers, comments on conditions and survey results, and confirmation that a copy was sent to the 88th PMC.
This form template is Attachment 10 to solicitation W911SA25QA072 for Grounds Maintenance Services at a location in Bay City, MI, with a performance period from April 2025 to March 2026 plus four option years and a six-month extension option. While the form itself is a template for pest control documentation, it indicates that pest management services are likely part of the broader grounds maintenance contract requirements.
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Other files
| File | Type | Posted |
|---|---|---|
| W911SA25QA072 Solicitation Amendment 0002 Final.pdf | ||
| W911SA25QA072 Attachment 06 - Price Schedule_CUI.xlsx | XLSX spreadsheet | |
| W911SA25QA072 Attachment 02 - AT-OPSEC.pdf | ||
| W911SA25QA072 Attachment 05 - Wage Determination Log.xlsx | XLSX spreadsheet | |
| W911SA25QA072 Attachment 01 - PWS.docx | DOCX document | |
| W911SA25QA072 Solicitation Final.pdf | ||
| W911SA25QA072 Amendment 01 Final.pdf | ||
| W911SA25QA072 Attachment 09 - Sample Service Ticket.docx | DOCX document | |
| W911SA25QA072 Attachment 07 - Drawing.pdf | ||
| W911SA25QA072 Attachment 08 - DOD Pesticides List.pdf | ||
| W911SA25QA072 Attachment 03 - PRS.xlsx | XLSX spreadsheet | |
| W911SA25QA072 Attachment 04 - Deliverables.docx | DOCX document |
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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 .