1 88th READINESS DIVISION WEED CONTROL RECORD FORM Version 1.3; 29 Jun 2017 A separate form shall be filled out for each operation. Please print for number 1-8. 1. Date of Application: _________________________ 2. Facility Name: ____________________________ 3. Type of Application: ________________________________________ (e.g., power spray, manual application etc.) 4. Site Description: ______________________________________ (e.g. lawn, unimproved ground, fence line, parking lot cracks, etc.) 5. Size of Area Treated: _________________________________ [Include unit, SF (square feet), LF (linear feet), AC (acre), CF (cubic feet)] 6. Applicator’s Name: ___________________________________ 7. Herbicide Used: 7a. Herbicide Trade Name: ___________________________________ 7b. Herbicide Active Ingredient: ________________________________________ 7c. EPA or State Reg # : ________________________________ 7d. Formulation: _____________________________________ 7d. Quantity of herbicide applied ____________________________ [(include unit, FL (fluid ounce), GA (gallon), ML (milliliter), LT (liter), LB (pound), DR (dry ounce), GR (gram), KG (kilogram)] 7e. Final Concentration Applied (%): _______________________________
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29 JUN 2017
2 8. Additional Comments: (survey results, wind conditions, sanitation deficiencies, etc.) _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ ______
9. Signature of Applicator: ___________________________________
10. Certification # of Applicator: _______________________________
11. (PWS #5.3.5) Copy of this form attached to invoice in iRAPT on (date): ___________________
Version 1.3
29 JUN 2017