PWS_Attachment_6_-_Pesticide_Application_Record.pdf
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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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