W911SA25QA081 Attachment 10 Universal Pest Management Application Reporting Form.docx
DOCX document 31 KB Posted
- Attached to
- Grounds Maintenance Services for Facility MO015 at Joplin, MO Federal contract opportunity
- Solicitation number
- W911SA25QA081
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 Joplin, MO. The form requires detailed documentation of pesticide/herbicide applications including date, location (indoor/outdoor), facility information, type of pest control operation, site description, target pest, area treated, applicator details, and comprehensive pesticide/herbicide information. Required pesticide documentation includes trade name, active ingredients, EPA registration number, formulation details, amount used (with units), final concentration, and total active ingredient applied. The form must be signed by a certified applicator and submitted to the 88th PMC.
This form is an attachment to solicitation W911SA25QA081 for grounds maintenance services at a facility in Joplin, MO, with a period of performance from April 1, 2025 to March 31, 2026, plus four option years and a six-month extension option. Quotes are due March 3, 2025 at 10:00 AM CT, with questions due by February 25, 2025. The Department of the Army Materiel Command Mission and Installation Contracting Command Fort McCoy is the contracting agency.
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Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| W911SA25QA081 Attachment 08 DOD Pesticides List.pdf | ||
| W911SA25QA081 Attachment 03 PRS.xlsx | XLSX spreadsheet | |
| W911SA25QA081 Solicitation.pdf | ||
| W911SA25QA081 Attachment 07 Drawing.pdf | ||
| W911SA25QA081 Attachment 04 Deliverables.docx | DOCX document | |
| W911SA25QA081 Attachment 01 PWS.pdf | ||
| W911SA25QA081 Attachment 02 AT-OPSEC.pdf | ||
| W911SA25QA081 Attachment 09 Sample Service Ticket.docx | DOCX document | |
| W911SA25QA081 Attachment 06 Price Schedule CUI.xlsx | XLSX spreadsheet | |
| W911SA25QA081 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 .