W911SA25QA084 Attachment 9 - 88th RD Universal Pest Management Application Reporting Form.docx
DOCX document 31 KB Posted
- Attached to
- Grounds Maintenance at KS065: Multiple Facilities in Kansas Federal contract opportunity
- Solicitation number
- W911SA25QA084
About this file
This document is a pest management application reporting form template required for a grounds maintenance contract at multiple facilities in Kansas, managed by the Army Materiel Command at Fort McCoy. The form requires detailed documentation of pest control operations, including date, location (indoor/outdoor), facility information, type of pest control operation, site description, target pest, area treated (with specific measurement units), applicator details, and comprehensive pesticide/herbicide information. The pesticide section requires specific documentation of trade names, active ingredients, EPA registration numbers, formulations, product quantities used (including dilution ratios), final concentration rates, and total active ingredient amounts applied. The form must be signed by a certified applicator and submitted to the 88th Readiness Division Pest Management Coordinator.
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Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| W911SA25QA0840001 SF30 Amendment.pdf | ||
| W911SA25QA0840001 SF 30 Amendment.pdf | ||
| W911SA25QA084 Attachment 5 - Wage Determination Log.xlsx | XLSX spreadsheet | |
| W911SA25QA084 Attachment 3 - PRS.xlsx | XLSX spreadsheet | |
| W911SA25QA084 Attachment 4 - Deliverables.docx | DOCX document | |
| W911SA25QA084 Attachment 8 - Grounds Service Ticket.docx | DOCX document | |
| W911SA25QA084 Attachment 1 - PWS.docx | DOCX document | |
| W911SA25QA084 Attachment 2 - AT-OPSEC.pdf | ||
| W911SA25QA084 Attachment 6 - Price Schedule - CUI.xlsx | XLSX spreadsheet | |
| W911SA25QA084 Attachment 7 - Facility Drawings.pdf | ||
| W911SA25QA084 Attachment 10 - DOD Pesticides List.pdf | ||
| W911SA25QA084 - SF1449 Solicitation.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)____________
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