PWS_Attachment_6_-_Pesticide_Application_Record.pdf

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Stonewall Jackson Lake Building and Grounds
Solicitation number
W911WN-18-T-3010
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PWS Attachment 6

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ATTACHMENT 6

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PESTICIDE APPLICATION RECORD 11 START DATE YYYYMMDD:
2 INSTALLATION:
3 SITE TREATED:
4 PEST TREATED:
5 PURPOSE:
SECTION I CONDITIONS DURING TREATMENT:
1 AIR TEMPERATURE Fahrenheit Degrees 12 WATER TEMPERATURE Fahrenheit Degrees if applicable:
3 OVERCAST Percentage 4 WIND DIRECTION N NE E SE S SW Wor NW 5 WIND VELOCITY mph:
SECTION II PESTICIDE RECORD:
1 COMMON NAME:
2 ACTIVE INGREDIENT AND PERCENTAGE:
5 REGISTRERED USE:
8 MIXTURE OR FORM APPLIED eg 20 to 1 Spray paste poured fumigation or Solid:
9 APPLICATION RATE 110 APPLICATION METHOD:
11 SPECIAL PRECAUTIONS TAKEN if none so state:
12 NUMBER OF PERSONNEL USED IN APPLICATION list other personnel in remarks below:
13 OTHER EQUIPMENT USED NOT PREVIOUSLY LISTED:
a UNITS TREATED:
b QUANTITY USED:
1 PREVIOUS:
1 PREVIOUS_2:
2 PRESENT:
2 PRESENT_2:
3 TOTAL:
3 TOTAL_2:
15 COOPERATING AGENCIES:
16 REMARKS:
SECTION Ill CERTIFIED APPLICATORS SIGNATURE CERTIFICATION:
I HEREBY CERTIFY THAT THIS INFORMATION IS A TRUE AND CORRECT RECORD OF THE PESTICIDE APPLICATION:
2a DATE YYYYMMDD:
b SIGNATURE Certified Applicator:
Text1: CELRP FORM 1031, APR 2010

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