Amendment_0001.pdf

AMENDMENT OF SOLICITATION/MODIFICATION OF CONTRACT

Except as provided herein, all terms and conditions of the document referenced in Item 9A or 10A, as heretofore changed, remains unchanged and in full force and effect.

15A. NAME AND TITLE OF SIGNER (Type or print)

30-105-04EXCEPTION TO SF 30

APPROVED BY OIRM 11-84

STANDARD FORM 30 (Rev. 10-83) Prescribed by GSA

FAR (48 CFR) 53.243

The purpose of this amendment is to correct the PWS Period of Performace Base and Option dates, accordingly and add 52.217-9 Option to Extend the Term of the Contract. All other terms and conditions remain the same.

1. CONTRACT ID CODE PAGE OF PAGES

1 15

16A. NAME AND TITLE OF CONTRACTING OFFICER (Type or print)

16C. DATE SIGNED

BY 12-Mar-2018

16B. UNITED STATES OF AMERICA15C. DATE SIGNED15B. CONTRACTOR/OFFEROR

(Signature of Contracting Officer)(Signature of person authorized to sign)

8. NAME AND ADDRESS OF CONTRACTOR (No., Street, County, State and Zip Code) X W9128F18Q0033

X 9B. DATED (SEE ITEM 11)

20-Feb-2018

10B. DATED (SEE ITEM 13)

9A. AMENDMENT OF SOLICITATION NO.

11. THIS ITEM ONLY APPLIES TO AMENDMENTS OF SOLICITATIONS

X The above numbered solicitation is amended as set forth in Item 14. The hour and date specified for receipt of Offer is extended, X is not extended.

Offer must acknowledge receipt of this amendment prior to the hour and date specified in the solicitation or as amended by one of the following methods:

(a) By completing Items 8 and 15, and returning copies of the amendment; (b) By acknowledging receipt of this amendment on each copy of the offer submitted;

or (c) By separate letter or telegram which includes a reference to the solicitation and amendment numbers. FAILURE OF YOUR ACKNOWLEDGMENT TO BE RECEIVED AT THE PLACE DESIGNATED FOR THE RECEIPT OF OFFERS PRIOR TO THE HOUR AND DATE SPECIFIED MAY RESULT IN

REJECTION OF YOUR OFFER. If by virtue of this amendment you desire to change an offer already submitted, such change may be made by telegram or letter, provided each telegram or letter makes reference to the solicitation and this amendment, and is received prior to the opening hour and date specified.

12. ACCOUNTING AND APPROPRIATION DATA (If required)

13. THIS ITEM APPLIES ONLY TO MODIFICATIONS OF CONTRACTS/ORDERS.

IT MODIFIES THE CONTRACT/ORDER NO. AS DESCRIBED IN ITEM 14.

A. THIS CHANGE ORDER IS ISSUED PURSUANT TO: (Specify authority) THE CHANGES SET FORTH IN ITEM 14 ARE MADE IN THE

CONTRACT ORDER NO. IN ITEM 10A.

B. THE ABOVE NUMBERED CONTRACT/ORDER IS MODIFIED TO REFLECT THE ADMINISTRATIVE CHANGES (such as changes in paying office, appropriation date, etc.) SET FORTH IN ITEM 14, PURSUANT TO THE AUTHORITY OF FAR 43.103(B).

C. THIS SUPPLEMENTAL AGREEMENT IS ENTERED INTO PURSUANT TO AUTHORITY OF:

D. OTHER (Specify type of modification and authority)

E. IMPORTANT: Contractor is not, is required to sign this document and return copies to the issuing office.

14. DESCRIPTION OF AMENDMENT/MODIFICATION (Organized by UCF section headings, including solicitation/contract subject matter where feasible.)

10A. MOD. OF CONTRACT/ORDER NO.

2. AMENDMENT/MODIFICATION NO. 5. PROJECT NO.(If applicable)

6. ISSUED BY

3. EFFECTIVE DATE

02-Mar-2018

CODE

U.S. ARMY CORPS OF ENGINEERS, OMAHA DIST

CONTRACTING OFFICE

1616 CAPITOL AVENUE

OMAHA NE 68102-4901

W9128F 7. ADMINISTERED BY (If other than item 6)

4. REQUISITION/PURCHASE REQ. NO.

CODE

See Item 6

FACILITY CODECODE

EMAIL:TEL:

W9128F18Q0033

SECTION SF 30 BLOCK 14 CONTINUATION PAGE

SUMMARY OF CHANGES

SECTION SF 1449 - CONTINUATION SHEET

The following have been added by reference:

52.217-9

The following have been modified:

PWS

PERFORMANCE WORK STATEMENT (PWS)

BROADLEAF SPRAYING

US ARMY CORPS OF ENGINEERS

(OAHE PROJECT/LAKE OAHE)

28563 Powerhouse Road

PIERRE, SD 57501

December 18, 2017

1.0 General Information.

1.1 Background: This is a service contract to provide all labor, supervision, equipment, chemical, supplies, and transportation to provide chemical application to control all broadleaf vegetation in the designated areas during the 2018- 2022 growing season. Approximately 55.6 acres are to be kept free of broadleaf vegetation on Oahe Project Corps of Engineers lands. Since these are residential areas special care must be taken around other people property (gardens, trees, flowers and shrubs). The contractor must be very aware of chemical drift. The contractor will be held liable for any damages that occur during the execution of this contract.

1.2 Scope of Work: Services include the control of all broadleaf vegetation in the designated areas during the growing season. The contractor shall perform these services in areas designated in this PWS (see maps). The contractor(s) or applicator(s) will provide all equipment, personnel, chemicals and chemical additives necessary to perform the spraying in accordance with All State and Federal laws.

NOTE: contractor will need to apply chemical to all areas with a hooded sprayer system (see attachment 3 for example). The Dam Crest Road will not need to be sprayed with the uses of a hood.

All areas that are to be sprayed adjacent to water must be sprayed with a federal and state approved chemical. The applicator(s) will have a current and valid applicators license for all chemicals and methods of applications and will provide the license number. The applicator(s) will provide pesticide application records (attachment 1) to this office within two weeks of completion of spraying.

1.2.1 Schedules: There will be two scheduled sprayings annually for this contract. The first spraying will be accomplished between the dates of May 1st to May 15th. The second spraying will be accomplished between the dates of July 1st to July 15th. The point of contact (POC) and contractor will determine the best date and time to accomplish the spraying based on weather and weed growth.

Contractor will not be paid until it is evident that all areas have been successfully treated for all broadleaf weeds in designated areas. Prior to spraying, the contractor(s) will contact the Project Office to set up a meeting to discuss any questions the contractor may have about the contract.

1.3 Period of Performance: The period of performance shall be for one (1) Base Offer and 4 options. The Period of Performance reads as follows:

Base Offer – 2018

01 May 2018 to 15 May 2018.

01 July 2018 to 15 July 2018.

Option 1 - 2019

01 May 2019 to 15 May 2019.

01 July 2019 to 15 July 2019.

Option 2 - 2020

01 May 2020 to 15 May 2020.

01 July 2020 to 15 July 2020.

Option 3 - 2021

01 May 2021 to 15 May 2021.

01 July 2021 to 15 July 2021.

Option 4 - 2022

01 May 2022 to 15 May 2022.

01 July 2022 to 15 July 2022.

1.4 Contractor Personnel. The contractor shall perform all work under this contract using his or her own forces except as provided in Paragraph 1.4.2 Subcontracting. Employees who perform this work shall be qualified persons on the contractor’s own payroll. All contractor vehicles shall be registered, licensed, and insured to meet all State and local laws. The contractor employees shall be skilled in and capable of performing the work under this contract. All employees of the contractor or subcontractor shall be at least 16 years of age or older.

1.4.2 Subcontracting. The contractor shall not subcontract any of the work without written approval of the Contracting Officer. Compliance with the provisions of this contract by subcontractors shall be the responsibility of the contractor.

1.5 Quality Control. The contractor shall develop and maintain an effective quality control program to ensure services are performed in accordance with this PWS. The contractor shall develop and implement procedures to identify, prevent, and ensure non-recurrence of defective services. The contractor’s quality control program is the means by which he assures himself that his work complies with the requirement of the contract.

1.6 Quality Assurance Surveillance Plan. The government will use a Quality Assurance Surveillance Plan (QASP) during the life of the contract to ensure that the contractor is performing the services required by this PWS in an acceptable manner. The Government develops the QASP and the Project Office administers the Plan through Quality Assurance Evaluators (QAE(s)).

1.6.1 The government will evaluate the contractor’s performance under this agreement in accordance with Part 7 of this PWS. The evaluation is primarily focused on what the government must do to ensure that the contractor has performed in accordance with the performance standards. It defines how the performance standards will be applied, the frequency of surveillance, and the minimum acceptable defect rate(s). The POC will be allowed at any time or place the contractor is on government property, to obtain a sample of the chemical for testing. If the contractor is found to be using a chemical off-label or a chemical not approved for use by the KO, the agreement will be terminated and the contractor shall be held liable for any damages and pay for the completion of the agreement by a different source. The POC will be allowed to observe and photograph all work activities conducted in completion of this PWS. The POC may inspect the work as the agreement progresses. The contractor will not be paid for any work performed that is deemed defective to the POC. Any defective service(s) noted by the POC shall be corrected at no additional cost to the government. The contractor shall be responsible to perform only that work specified within the PWS, and shall receive no compensation for any work performed that is not specified within the PWS. No government personnel will be allowed to assist the contractor in actual spraying operations or supervision of the contractor's personnel.

1.7 Hours of Operation: The contractor is responsible for conducting business, sunrise to sunset CST, Monday thru Sunday, except federal holidays or when the government facility is closed due to local or national emergencies, administrative closings, or similar government directed facility closings. For other than firm fixed price contracts, the contractor will not be reimbursed when the government facility is closed for the above reasons. The contractor must at all times maintain an adequate workforce for the uninterrupted performance of all tasks defined within this PWS when the government facility is not closed for the above reasons. When hiring personnel, the contractor shall keep in mind that the stability and continuity of the workforce are essential.

1.8 Pre-Work Meeting. Prior to commencing any activities, the contractor shall arrange a Pre-work Meeting with the COR. The Meeting shall discuss the work requirements, scheduling, submittal process, review of the Activity Hazard Analysis (AHA), and Abbreviated Accident Prevention Plan (AAP). At least one (1) week prior to commencing work, the contractor shall coordinate their proposed work schedule with the COR.

1.9. Submittals. Prior to commencement of services, the contractor shall submit the following documents to the COR for review and approval:

a. Activity Hazard Analysis (AHA);

b. Abbreviated Accident Prevention Plan (APP)

c. List of who will perform work on this contract;

d. Proof of Insurance for Contractors and Subcontractors;

e. Material Safety Data Sheets (MSDS): The Contractor shall supply MSDS’s for all cleaning solutions, detergents, and materials used on the project.

1.10 Standards and Regulations. The contractor shall perform to the standards in the contract and comply with all Local, State, and Federal Regulations during the services performed. The contractor is responsible for ascertaining the extent to which these regulations affect the operations resulting from this contract. The contractor shall comply will all applicable regulations. Applicable regulations include, but are not limited to the following:

a. Code of Federal Regulations (CFR), Title 36, Chapter III, Part 327, Rules and Regulations Governing Public Use on Corps of Engineers Water Resource Development Projects EP 1165-2-316 (http://www.publications.usace.army.mil/Portals/76/Publications/EngineerPamphlets/EP_ 1165-2-316.pdf?ver=2013-08-22-104526-670)

b. Engineering Manual (EM) 385-1-1 (USACE – Safety and Health Requirements Manual), dated November 2014;

http://www.publications.usace.army.mil/Portals/76/Publications/EngineerManuals/EM_3 85-1-1.pdf

c. Occupational Safety and Health Standards (29 CFR 1910);

1.10.1 Activity Hazard Analysis (AHA). Contractor shall prepare AHAs IAW Paragraph 01.A.14 or 01.A.15 of the EM 385-1-1. If using Paragraph 01.A.15, prepare AHAs IAW Figure 1-2.

Note: Contractors and other individual employer’s typically use Job Safety Analyses (JSAs), Job Hazard Analyses (JHAs), or similar Risk Management assessment tools. The government shall consider these documents equivalent to, and acceptable substitutes for, the USACE’s AHA provided the data collected is the same as that required by the AHA, commensurate with the type of services performed by the contractor.

1.10.2 Abbreviated Accident Prevention Plan (APP). EM 385-1-1 in its entirety may be too complex for the type of work performed under these contracts; Contractors may reference Appendix A, for abbreviated Accident Prevention Plan (APP). The contractor shall only need to submit items in Appendix A that are pertinent to the contract. The contractor shall use a qualified person to prepare the site-specific Abbreviated Accident Prevention Plan (AAPP). Prepare the AAPP in accordance with the format and requirements of the EM 385-1-1 and supplemented herein. The contractor shall sign and submit the APP for Government approval prior to the start of work onsite.

1.11 Physical Security

1.11.1 The contractor shall be responsible for safeguarding all government facilities, property, and materials provided for contractor use. The contractor shall secure at all times all government facilities, property, and materials. Specific security conditions may change based on threats to national defense, and based on the risk of specific facilities to these threats. The contractor shall abide by these changing conditions at all times.

1.12 Payment

1.12.1 The government will make payment bi-annually, after the government has inspected and accepted the services provided by the contractor, and the government has reviewed, approved, and processed the contractor’s invoice. The contractor shall submit the invoice to the COR and/or any other person that has been designated in the contract to receive the invoice.

1.12.2 The contractor must provide the contractor’s name, address, contract number, period of services completed (i.e., for the month of January or for the period of performance of January 1 through February 23), CLIN number and specific quantities of work performed (i.e., 1 Month, 40 days, 100 acres, etc.), and total requested, for an invoice to be considered proper.

1.13 Place of Performance: The work to be performed under this agreement shall be performed on federal land administered by the USACE Oahe Project, Pierre, South Dakota.

1.14 Security Requirements: All Contractor and all associated sub-contractors employees shall comply with applicable installation, facility and area commander installation/facility access and local security policies and procedures (provided by government representative). The Contractor shall also provide all information required for background checks to meet installation access requirements to be accomplished by installation Provost Marshal Office, Director of Emergency Services or Security Office. Contractor workforce must comply with all personal identity verification requirements as directed by DOD, HQDA and/or local policy. In addition to the changes otherwise authorized by the changes clause of this contract, should the Force Protection Condition (FPCON) at any individual facility or installation change, the Government may require changes in Contractor security matters or processes. Directions for background check are in paragraph 1.14.3

1.14.1 Submit a complete, updated and signed, list of all Contractor and subcontractor personnel, including their titles and intended working hours, who will be working on site prior to start of work. This listing shall be revised and resubmitted when personnel changes occur.

1.14.2 Personnel Risk Assessment

A minimum of seven days prior to engaging in work submit, to the CO or Project POC, a Personnel Risk Assessment (PRA) for each employee requiring authorized unescorted access to the Jobsite. The Contractor employee will only be allowed authorized unescorted physical access after the PRA is shown to and approved by the Government.

1.14.3 Authorized Unescorted Access Requirements

Perform a PRA on all Contractor personnel that require authorized unescorted access to the Jobsite. Costs associated with the execution of the PRA shall be at the expense of the Contractor.

The content of the PRA is defined by the requirements as follows:

a. Criminal Check - Obtain a criminal background check, completed within the last seven years, on all Contractor personnel that require authorized unescorted access to the Jobsite.

A minimum of a 7-year criminal background check with the state patrol office shall be performed from all states of residence and employment, for the past seven years. The COR through the Contacting Officer will approve, disapprove, or revoke authorized unescorted access to the Jobsite as a result of the seven-year background check in accordance with Army Directive 2014-05 Enclosure 2.

b. Identity Verification - Contractor employees shall provide positive verification of individual identity prior to authorized unescorted access to the Jobsite. Acceptable forms of identity verification are documents issued by a federal Government agency that include: the individual's photograph, name, and date of birth, such as a passport or military identification (ID) card. Additionally, a state issued driver's license or ID card is acceptable for identity verification.

c. The Criminal Check and Identity Verification shall be updated at least every seven years for each employee requiring authorized unescorted access to the Jobsite.

d. Escort Requirements - Contractor personnel not cleared for authorized access to the Jobsite may be escorted by Government or Contractor personnel that have authorized unescorted access to the Jobsite. All costs related to the escorting of non-cleared personnel shall be at the expense of the Contractor. Additional burden shall not be placed upon the Government to provide these escorts. Prior to access, coordination with the Project Security Officer is required, including but not limited to:

(1) Verification of identity with photo identification

(2) Name of escorting individual and verification of unescorted status

(3) Time of entry into the Jobsite

(4) Time exiting the Jobsite.

1.14.4 Physical Access:

The following verbiage should be added to paragraph “1.14.5 Special Qualifications”

1.14.4.1 Special Qualifications: All contract employees, including subcontractor employees who are not in possession of the appropriate access privileges, will be escorted in areas where they may be exposed to sensitive materials and/or sensitive or restricted areas.

1.14.4.2 The Contractor must pre‐screen Candidates using the E‐verify Program (http://www.dhs.gov/E‐Verify) website to meet the established employment eligibility requirements. The Vendor must ensure that the Candidate has two valid forms of Government issued identification prior to ensure the correct information is entered into the E‐verify system.

An initial list of verified/eligible Candidates must be provided to the COR no later than 3 business days after the initial contract award. When contracts are with individuals, the individuals will be required to complete a Form I-9, Employment Eligibility Verification, with the designated Government representative. This Form will be provided to the Contracting Officer and shall become part of the official contract file.

2.0 Definitions and Acronyms:

2.1. Definitions.

2.1.1. Contractor. A supplier or vendor awarded a contract to provide specific supplies or service to the government. The term used in this contract refers to the prime.

2.1.2. Contracting Officer. A person with authority to enter into, administer, and or terminate contracts, and make related determinations and findings on behalf of the government. Note: The only individual who can legally bind the government.

2.1.3. Contracting Officer's Representative (COR). An employee of the U.S. Government appointed by the contracting officer to administer the contract. Such appointment shall be in writing and shall state the scope of authority and limitations. This individual has authority to provide technical direction to the Contractor as long as that direction is within the scope of the contract, does not constitute a change, and has no funding implications. This individual does NOT have authority to change the terms and conditions of the contract.

2.1.4. Defective Service. A service output that does not meet the standard of performance associated with the Performance Work Statement.

2.1.5. Deliverable. Anything that can be physically delivered, but may include non-manufactured things such as meeting minutes or reports.

2.1.6. Key Personnel. Contractor personnel that are evaluated in a source selection process and that may be required to be used in the performance of a contract by the Key Personnel listed in the PWS. When key personnel are used as an evaluation factor in best value procurement, an offer can be rejected if it does not have a firm commitment from the persons that are listed in the proposal.

2.1.7. Physical Security. Actions that prevent the loss or damage of Government property.

2.1.8. Quality Assurance. The government procedures to verify that services being performed by the Contractor are performed according to acceptable standards.

2.1.9. Quality Assurance Surveillance Plan (QASP). An organized written document specifying the surveillance methodology to be used for surveillance of contractor performance.

2.1.10. Quality Control. All necessary measures taken by the Contractor to assure that the quality of an end product or service shall meet contract requirements.

2.1.11. Subcontractor. One that enters into a contract with a prime contractor. The Government does not have privity of contract with the subcontractor.

2.1.12 Work Day. The number of hours per day the Contractor provides services in accordance with the contract.

2.1.12 Work Week. Monday through Friday, unless specified otherwise.

2.2. Acronyms:

AR Army Regulation CFR Code of Federal Regulations CONUS Continental United States (excludes Alaska and Hawaii) COR Contracting Officer Representative DA Department of the Army DOD Department of Defense FAR Federal Acquisition Regulation NLT No Later Than OCI Organizational Conflict of Interest POC Point of Contact PRS Performance Requirements Summary PWS Performance Work Statement QA Quality Assurance QAP Quality Assurance Program QASP Quality Assurance Surveillance Plan QC Quality Control

3.0 Government Furnished Items and Services:

3.1. Services: N/A.

3.2 Facilities: The Government shall NOT make available to the Contractor any space or facilities for storage of equipment or supplies, unless negotiated by the POC.

3.3 Utilities: The Government may provide water at no extra cost to the contractor while the water system is working or may be obtained from other sources approved by the COR. If obtained from sources other than the Government water supply systems, all arrangements and payments, if any, will be made by the Contractor. The Contractor shall be responsible for operating under conditions that preclude the waste of utilities, which include turning off the water faucets or valves after using the required amount to accomplish cleaning. The Contractor shall be responsible to furnish all equipment necessary to load, contain, and transport water for cleaning.

3.4 Materials: N/A

4. Contractor Furnished Items and Responsibilities:

4.1 General: The Contractor shall furnish all supplies, equipment, personnel, supervision, facilities and other items and services required to perform work under this contract that are not listed under Section 3 of this PWS.

4.2 Materials: Any chemical, additives, or other substances used the Contractor must supply the COR with Material Data Safety Sheets for any product used on this contract.

4.3 Equipment: The Contractor shall furnish all equipment to meet the requirements under this PWS. NOTE: contractor will need to apply chemical to all areas with a hooded sprayer system (see attachment 3 for example). All equipment used to perform work under this contract must be in good operating and mechanical condition. All equipment will be equipped with the manufacturers recommended safety protective devices to insure worker and public safety at all times. The Contractor will provide to his/her workers proper eye, ear, head, and foot protection equipment for the job. The equipment and operators must also comply with the U.S.

Army Corps of Engineers Safety and Health Requirements Manual EM 385-1-1.4.6.1.

5. SPECIFIED TASKS:

5.1. Basic Services: The contractor shall provide services for chemical application. The contractor shall perform chemical application services on approximately 55.6 acres of federal land administered by the USACE Oahe Project. Services include 1) All designated areas will need to be completely covered with an approved broadleaf vegetation chemical, and 2) preparation and submittal of invoices for payment, chemical MSDS sheet, spray logs and all other documentation requires under PWS.

5.2. Task Heading:

5.2.1 Areas to be sprayed / controlled (see attachment 2, for specific map locations):

LOTS ACRES

Pierre 61 11.6

Fort Pierre 42 10.6

Frontier Road 5 4.1

Visitor Center 8.3

Powerhouse 11.3

Project Office 5

Dam Crest Road 4.7

Total 55.6

5.2.2. Broadleaf spraying: All designated areas will need to be completely covered with an approved broadleaf chemical treatment. There will be two scheduled sprayings annually for this contract. The first spraying will be accomplished between the dates of May 1st to May 15th. The second spraying will be accomplished between the dates of July 1st to July 15th. The point of contact (POC) and contractor will determine the best date and time to accomplish the spraying based on weather and weed growth.

5.2.3. Chemical Application Documentation: The contractor will be required to provide all MSDS sheet for each chemical/additive used. The contractor shall provide a Pesticide Application Record (attachment 1) for each day spraying is performed. If other forms of Pesticide Application Record are to be used it will need to be approved by the POC.

5.2.4. Invoices: The contractor shall be required to prepare itemized invoices to receive payment for services rendered.

6.0 Performance Requirements Summary. The contractor service requirements are summarized into performance objectives that relate directly to mission essential items. The performance threshold briefly describes the minimum acceptable levels of service required for each requirement. These thresholds are critical to mission success.

Performance Objective

Standard Performance Threshold

Method of Surveillance

PRS # 1.

Broadleaf spraying :

PWS paragraph 5.2

The Contractor shall spray all designated areas with approved pre-emergent chemical.

In accordance with Part

5.2 and attachment 2.

Zero Deviation From Standard.

100% inspection

PRS #2

Chemical Application Documentation:

PWS paragraph 5.2

The contractor will be responsible to provide all MSDS sheet and Pesticide Application Records (attachment 1) to the COR.

IAW Part 5.2 Section C

Zero Deviation From Standard.

100% inspection

PRS #3

Invoices:

PWS paragraph 5.2

The Contractor shall submit all invoices to the

POC.

IAW Part 5.2 Section D

Zero Deviation From Standard.

100% inspection

7.0 Attachment/Technical Exhibit List:

7.1. Attachment 1 – Pesticide Application Record

7.2. Attachment 2 – Spray Map Locations

7.3. Attachment 3 – Example of hooded sprayer attachment

ATTACHMENT 1

PESTICIDE APPLICATION RECORD

U.S. ARMY CORPS OF ENGINEERS, OMAHA DISTRICT, OAHE PROJECT

Date: _________ Area or Treatment Site: ___________________________ Total Acres Treated:_________

WEATHER CONDITIONS DURING TREATMENT:

Temperature: A.M. P.M._______ Wind Speed:A.M. P.M. Wind Direction: A.M. P.M.__ __

TIME OF APPLICATION: Beg Time: ________ End Time: ________ Beg Time: ________ End Time: ________ Total Hours: _________

APPLICATION EQUIPMENT USED: PICKUP - BOOM HANDGUN

ATV - BOOM HANDWAND____

GRANULAR________ BACKPACK ____

TARGET WEEDS CONTROLLED:__________________________________________

GROWTH STAGE: DORMANT ( ) ACTIVE TO FLOWER ( ) MATURE TO SEED SET ( )

MIXTURE AND/OR FORM APPLIED: ___________________________________________

Chemical Used: _____________________ Common Name: ____________________________

Manufacturer: __________________________ EPA Registration # _____________

Total Quantity: _____________________ APPLICATION RATE: _________________________________________

Chemical Used: _____________________ Common Name: ____________________________

Chemical Used: _____________________ Common Name: ____________________________

SPECIAL PRECAUTIONS TAKEN: ________________________________________

PROBLEMS ENCOUNTERED AT TIME OF APPLICATION:

APPLICATOR’S NAME & LICENSE #:

(End of Summary of Changes)