W911SA25QA073 Attachment 10 - Universal Pest Management Application Reporting Form.docx
DOCX document 31 KB Posted
- Solicitation number
- W911SA25QA073
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. The form requires detailed documentation of pest control activities including the date, location (indoor/outdoor), facility information, type of pest control operation, site description, target pest, area treated, and applicator details.
The form requires specific pesticide/herbicide information including trade name, active ingredients, EPA registration numbers, formulation details, amount of product used (with precise unit measurements), final concentration applied, and total amount of active ingredient used. The form must be signed by a certified applicator and submitted to the 88th PMC. This form is an attachment to solicitation W911SA25QA073 for grounds maintenance services at a Belton, MO location, with performance period from April 2025 to March 2026 plus four option years and a six-month extension option.
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Other files
| File | Type | Posted |
|---|---|---|
| W911SA25QA073 Solicitation Final.pdf | ||
| W911SA25QA073 Attachment 02 - AT-OPSEC.pdf | ||
| W911SA25QA073 Attachment 07 - Drawing.pdf | ||
| W911SA25QA073 Attachment 01 - PWS.docx | DOCX document | |
| W911SA25QA073 Attachmet 05 - Wage Determination Log.xlsx | XLSX spreadsheet | |
| W911SA25QA073 Attachment 06 - Price Schedule_CUI.xlsx | XLSX spreadsheet | |
| W911SA25QA073 Attachment 08 - DOD Pesticides List.pdf | ||
| W911SA25QA073 Attachment 04 - Deliverables.docx | DOCX document | |
| W911SA25QA073 Attachment 03 - PRS.xlsx | XLSX spreadsheet | |
| W911SA25QA073 Attachment 09 - Sample Service Ticket.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 .