Attachment_1.pdf

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GP Weed Spraying
Solicitation number
W9128F19Q0067
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Pesticide Application Record

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TECHNICAL EXHIBIT 4

PESTICIDE APPLICATION RECORD

DISTRICT __Omaha___ Date: ___________________

LOCATION _______________________ PROJECT __Gavins Point__________

U.S. ARMY CORPS OF ENGINEERS Address: _PO Box 710___________ PEST CONTROL PROGRAM City: _Yankton, SD 57078_____ POST-APPLICATION DOCUMENTATION FORM Phone: _(402) 667-7873_________

CONTRACTOR ______________________ APPLICATOR _________________________

Address: _____________________________ Address: ______________________________ City: _____________________________ City: ______________________________ Phone: _____________________________ Phone: ______________________________

TARGET PEST _ ________________________________ ___________

Date of Application

Time of Application

Air Temp Relative Humidity

Cloud Cover

Wind Speed

Wind Direction

Acreage Treated

: to

DESCRIPTION OF TREATED AREA ____________________________________________________

PESTICIDE INFORMATION

PESTICIDE (TRADE NAME) ___________________________________________________________

FORM APPLIED _____________________________________________________________________

ACTIVE INGREDIENTS _______________________________________________________________

EPA REGISTRATION # ______________________ EPA CLASSIFICATION ____________________

APPLICATION INFORMATION

HOW THE PESTICIDE WAS MIXED ____________________________________________________

APPLICATION RATE _________________________________________________________________

TOTAL AMOUNT OF PESTICIDE APPLIED ______________________________________________

APPLICATION EQUIPMENT USED _____________________________________________________

TOTAL NUMBER OF HOURS TO COMPLETE APPLICATION ______________________________

DISPOSAL INFORMATION

DISPOSAL DATE _____________________ LOCATION ___________________________________

METHOD ____________________________________________________________________________ *NOTE: If an aquatic application is made, a weather forecast for the 24 hour period immediately following the application must be submitted with this record.

APPLICATOR SIGNATURE ___________________________________________________________

Date:
CONTRACTOR:
APPLICATOR:
Address:
Address_2:
City:
City_2:
Phone:
Phone_2:
Date of ApplicationRow1:
Air Temp to:
Relative Humidity to:
Cloud Cover to:
Wind Speed to:
Wind Direction to:
Acreage Treated to:
DESCRIPTION OF TREATED AREA 1:
DESCRIPTION OF TREATED AREA 2:
PESTICIDE TRADE NAME:
FORM APPLIED:
ACTIVE INGREDIENTS 1:
ACTIVE INGREDIENTS 2:
EPA REGISTRATION:
EPA CLASSIFICATION:
HOW THE PESTICIDE WAS MIXED:
APPLICATION RATE:
TOTAL AMOUNT OF PESTICIDE APPLIED:
APPLICATION EQUIPMENT USED:
TOTAL NUMBER OF HOURS TO COMPLETE APPLICATION:
DISPOSAL DATE:
LOCATION:
METHOD:
Location:
HR1:
min1:
a/p1: [ ]
HR2:
min2:
a/p2: [ ]

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