State of Washington Department of Agriculture Olympia, Washington 98504 | PESTICIDE APPLICATION RECORD (Version 1) NOTE: This form must be completed same day as the application and it must be retained for 7 years (Ref. chapter 17.21 RCW) | |||||
1. | Date of Application - Year: . . . . . . . . . . . . | Month: . . . . . . . . . . . . | Day: . . . . . . . . . . . . | Start Time: . . . . . . . . . . . . | ||
Stop Time: . . . . . . . . . . . . | ||||||
2. | Name of person for whom the pesticide was applied: . . . . . . . . . . . . | |||||
Firm Name (if applicable): . . . . . . . . . . . . | ||||||
Street Address: . . . . . . . . . . . . | City: . . . . . . . . . . . . | State: . . . . . . . . . . . . | Zip: . . . . . . . . . . . . | |||
3. | Licensed Applicator's Name (if different from #2 above): . . . . . . . . . . . . Firm Name (if applicable): . . . . . . . . . . . . | License No.: . . . . . . . . . . . . | ||||
Tel No.: . . . . . . . . . . . . | ||||||
Street Address: . . . . . . . . . . . . | City: . . . . . . . . . . . . | State: . . . . . . . . . . . . | Zip: . . . . . . . . . . . . | |||
4. | Name of person(s) who applied the pesticide (if different from #3 above): . . . . . . . . . . . . | |||||
. . . . . . . . . . . . | License No(s). If applicable: . . . . . . . . . . . . | |||||
5. | Application Crop or Site: . . . . . . . . . . . . | |||||
6. | Total Area Treated (acre, sq. ft., etc.): . . . . . . . . . . . . | |||||
7. | Was this application made as a result of a WSDA Permit? | [] No | [] Yes (If yes, give Permit No.) # . . . . . . . . . . . . | |||
8. | Pesticide Information (please list all information for each pesticide, including adjuvants (buffer, surfactant, etc.), in the tank mix): |
a) Full Product Name | b) EPA Reg. No. | c) Total Amount of Pesticide Applied in Area Treated | d) Pesticide Applied/Acre (or other measure) | e) Concentration Applied |
/ | ||||
/ | ||||
/ | ||||
/ | ||||
/ |
9. | Address or exact location of application. NOTE: If the application is made to one acre or more of agricultural land, the field location must be shown on the map on page two of this form. | ||||
10. | Wind direction and estimated velocity (mph) during the application: . . . . . . . . . . . . | ||||
11. | Temperature during the application: . . . . . . . . . . . . | ||||
12. | Apparatus license plate number (if applicable): . . . . . . . . . . . . | ||||
13. | [] Air | [] Ground | [] Chemigation | ||
14. | Miscellaneous Information: | ||||
AGR 4226 (Rev. 4/07) |
Location of Application: If the application covers more than one township or range, please indicate the township & range for the top left section of the map only: | |||||||||||||||||
Township: . . . . . . . . . . . . | N | ||||||||||||||||
Range: E OR W (please indicate:) . . . . . . . . . . . . | |||||||||||||||||
Section(s): . . . . . . . . . . . . | |||||||||||||||||
Block: . . . . . . . . . . . . | Farm Unit: . . . . . . . . . . . . | ||||||||||||||||
or GPS: . . . . . . . . . . . . | |||||||||||||||||
County: . . . . . . . . . . . . | |||||||||||||||||
PLEASE NOTE: | |||||||||||||||||
The map is divided into 4 sections with each section divided into quarter-quarter sections. Please complete it by marking the appropriate section number(s) on the map and indicate as accurately as possible the location of the area treated. | |||||||||||||||||
Section: . . . . . . . . . . . . | Section: . . . . . . . . . . . . | ||||||||||||||||
(UP ARROW) | |||||||||||||||||
| | |||||||||||||||||
(UP ARROW) | One | | | Mile | ||||||||||||||
N | (DOWN ARROW) | ||||||||||||||||
Section: . . . . . . . . . . . . | Section: . . . . . . . . . . . . | ||||||||||||||||
Miscellaneous Information: |
INSTRUCTIONS |
Pesticide Application Record (Version 1) AGR 4226 (Rev. 4/07) |
1. Date may be spelled out or indicated numerically. Time must be indicated as start and stop times. |
2. Include first and last name. |
3. If the person's name is the same as No. 2, write "same" in the space for the licensed applicator's name and include the license number (if applicable) and telephone number. |
4. Include first and last name(s). |
5. Indicate type of land or site treated, not location. Examples: Wheat, apples, rights of way, lawn, trees and shrubs, crawl space, wall voids, etc. |
6. May also be stated in terms such as linear feet, cubic feet, etc. (Specify the term to which the number refers.) If spot treatment, write spot treatment. |
7. If the application was made under permit, but no permit number was issued, indicate the date the permit was issued. |
8.a) Brand name found on the pesticide label including adjuvants (buffer, spreader, sticker, surfactant, etc.). |
b) This number is found on the pesticide container label. If the material is being applied under a federal experimental use permit and no EPA Reg. No. exists, list the federal experimental use permit number. If the material is a spray adjuvant (buffer, spreader, sticker, surfactant, etc.) write "adjuvant" in this space and add the state registration number. |
c) Indicate the amount of pesticide formulation (product) applied to the total area listed on line 6. |
d) Other measures may include amount/sq. ft., amount/cu. ft., amount/linear ft., etc. |
e) This may be listed in various ways, such as: Amount of product/100 gallons water, percent formulation in the tank mix (i.e., 1%), gallons per acre of output volume, ppm (or other measure), or inches of water applied (chemigation). Specify the term to which the number refers. |
9. Agricultural land includes such areas as forest lands and range lands. It does not include transportation and utility rights of way. |
10. Indicate the direction from which the wind is blowing. Measure wind velocity in mph. If the wind varies in direction and velocity during the application, indicate the range of variance (i.e., S-SW 3-7 mph). Wind readings shall be obtained in close proximity to the application site. |
11. Indicate temperature in degrees Fahrenheit. (It may be indicated as the range encountered during application.) Temperature readings shall be obtained in close proximity to the application site. |
12. This does not apply to private applicators or public agencies. |
13. Check one. |
14. Depth of application/inches of water (chemigation). |
15. This space is available for any additional information you may wish to include. |
Form AGR 4226 (Rev. 4/07) Pg. 2 |
State of Washington Department of Agriculture Olympia, Washington 98504 | PESTICIDE APPLICATION RECORD (Version 2) |
NOTE: Application information must be completed same day as the application and must be retained for seven years (Ref. chapter 17.21 RCW) |
1. Name & Address of Person for Whom Pesticide was Applied . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . | 2. Applicator Name and Address (if different from # 1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Tel. No. . . . . . . . . Lic. No. . . . . . . . . | ||||||||
3. Full, complete address or exact location of application (NOTE: If the application is made to one acre or more of agricultural land, the field location must be shown on the map on page two of this form) | 4. Misc. Info: | ||||||||
5. Date and Time of Application (Start and Stop) | 6. Crop or Site Treated | 7. Acres Treated (or other measure) | 8. FULL PRODUCT NAME | 9. EPA Registration Number | 10. Amount of Product Applied | 11. Concentration | 12. Weather Conditions (wind direction, velocity, temperature). Apparatus License Plate No. and Name and License No. of person(s) who applied pesticide | ||
Rate per acre (or other measure) | Total Product Applied | ||||||||
[] Air [] Ground [] Chemigation | |||||||||
[] Air [] Ground [] Chemigation | |||||||||
[] Air [] Ground [] Chemigation | |||||||||
[] Air [] Ground [] Chemigation | . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . | . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . | . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . | . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . | . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . | ||||
AGR 4235 (Rev. 4/07) |
Location of Application (If the application covers more than one township or range, please indicate the township & range for the top left section of the map only: | ||||||||||||||||||||||
Township: . . . . . . . . . . . . | N | Section: . . . . . . . . . . . . | Section: . . . . . . . . . . . . | |||||||||||||||||||
Range: E OR W (please indicate) . . . . . . . . . . . . | (UP ARROW) | |||||||||||||||||||||
Section(s): . . . . . . . . . . . . | One | | | Mile | |||||||||||||||||||
Block: . . . . . . . . . . . . | Farm Unit: . . . . . . . . . . . . | |||||||||||||||||||||
or GPS: . . . . . . . . . . . . | ||||||||||||||||||||||
County: . . . . . . . . . . . . | (UP ARROW) | | | ||||||||||||||||||||
N | (DOWN ARROW) | |||||||||||||||||||||
PLEASE NOTE: | ||||||||||||||||||||||
The map is divided into 4 sections with each section divided into quarter-quarter sections. Please complete it by marking the appropriate section number(s) on the map and indicate as accurately as possible the location of the area treated. | ||||||||||||||||||||||
Section: . . . . . . . . . . . . | Section: . . . . . . . . . . . . | |||||||||||||||||||||
AGR 4235 Pg. 2 |
INSTRUCTIONS |
Pesticide Application Record (Version 2) AGR 4235 (Rev. 4/07) |
1. Include first and last name. |
2. If the person's name is the same as No. 1, write "same" in the space for the licensed applicator's name and include the license number (if applicable) and telephone number. |
3. Agricultural land includes such areas as forest lands and range lands. It does not include transportation and utility rights of way. |
4. This space is available for any additional information you may wish to include. |
5. Date may be spelled out or indicated numerically. Application start and stop times must be indicated. |
6. Indicate type of land or site treated, not location. Examples: Wheat, apples, rights of way, lawn, trees and shrubs, crawl space, wall voids, etc. |
7. May also be stated in terms such as linear feet, cubic feet, etc. (Specify the term to which the number refers.) If spot treatment, write spot treatment. |
8. Brand name found on the pesticide label including adjuvants (buffer, spreader, sticker, surfactant, etc.). |
9. This number is found on the pesticide container label. If the material is being applied under a federal experimental use permit and no EPA Reg. No. exists, list the federal experimental use permit number. If the material is a spray adjuvant (buffer, spreader, sticker, surfactant, etc.) write "adjuvant" in this space and add the state registration number. |
10. Rate per acre: Other measures may include amount/sq. ft., amount/linear ft., etc. Specify the term to which the number refers. Total product applied is the total product applied between start and stop times. |
11. This may be listed in various ways, such as: Amount of product/100 gallons water, percent formulation in the tank mix (i.e., 1%), gallons per acre of output volume, ppm (or other measure), or inches of water applied (chemigation). Specify the term to which the number refers. |
12. Weather conditions must include the direction from which the wind is blowing, measure velocity in mph. If the wind varies in direction and velocity during the application, indicate the range of variance (i.e., S-SW 3-7 mph). Temperature must also be indicated in degrees Fahrenheit and may be listed as the range encountered during the application. Wind and temperature readings shall be obtained in close proximity to the application site. |
The apparatus license plate number does not apply to private applicators or public agencies. |
Include first and last name(s) of person(s) who applied the pesticide. Include license number(s) if applicable. |
State of Washington Department of Agriculture Olympia, Washington 98504 | PESTICIDE APPLICATION RECORD (Version 3) NOTE: This form must be completed same day as the application and it must be retained for 7 years (Ref. chapter 17.21 RCW) | |||||
1. | Date of Application - Year: . . . . . . . . . . . . | Month: . . . . . . . . . . . . | Day(s): . . . . . . . . . . . . | |||
2. | Name of person for whom the pesticide was applied: . . . . . . . . . . . . | |||||
Firm Name (if applicable): . . . . . . . . . . . . | ||||||
Street Address: . . . . . . . . . . . . | City: . . . . . . . . . . . . | State: . . . . . . . . . . . . | Zip: . . . . . . . . . . . . | |||
3. | Licensed Applicator's Name (if different from #2 above): . . . . . . . . . . . . | License No.: . . . . . . . . . . . . | ||||
Firm Name (if applicable): . . . . . . . . . . . . | Tel. No.: . . . . . . . . . . . . | |||||
Street Address: . . . . . . . . . . . . | City: . . . . . . . . . . . . | State: . . . . . . . . . . . . | Zip: . . . . . . . . . . . . | |||
4. | [] Air | [] Ground | [] Chemigation | |||
5. | Application Crop or Site: . . . . . . . . . . . . | |||||
6. | Total Area Treated (acre. sq. ft., etc.) . . . . . . . . . . . . | |||||
7. | Was this application made as a result of a WSDA Permit? | [] No | [] Yes (If yes, give Permit No.) # . . . . . . . . . . . . | |||
8. | Pesticide Information (list all information for each pesticide including adjuvants in the tank mix): |
a) Full Product Name | b) EPA Reg. No. | c) Total Amount of Pesticide Applied in Area Treated | d) Pesticide Applied/Acre (or other measure) | e) Concentration Applied | f) Depth of Application (Chemigation) |
/ | ||||||
/ | ||||||
/ | ||||||
/ | ||||||
/ |
9. | Address or exact location of application. NOTE: If the application is made to one acre or more of agricultural land, the field location must be shown on the map on page two of this form. |
10. Date | 11. Name of person(s) making the application | 12. License No. | 13. Apparatus Lic. Plate No. | 14. Time | 15. Acres Completed | 16. Wind | 17. Temp | ||
Start | Stop | Dir. | Vel. | ||||||
(mph) | |||||||||
AGR 4236 (Rev. 4/07) | |||||||||
10. Date | 11. Name of person(s) making the application | 12. License No. | 13. Apparatus Lic. Plate No. | 14. Time | 15. Acres Completed | 16. Wind | 17. Temp | ||
Start | Stop | Dir. | Vel. (mph) |
Location of Application (If the application covers more than one township or range, please indicate the township & range for the top left section of the map only. | |||||||||||||||||||
Section: . . . . . . . . . . . . | Section: . . . . . . . . . . . . | ||||||||||||||||||
(UP ARROW) | |||||||||||||||||||
Township: . . . . . . . . . . . . | N | | | |||||||||||||||||
Range: E OR W (please indicate): . . . . . . . . . . . . | (UP ARROW) | One | | | Mile | |||||||||||||||
Section(s): . . . . . . . . . . . . | N | (DOWN ARROW) | |||||||||||||||||
Block: . . . . . . . . . . . . | Farm Unit: . . . . . . . . . . . . | ||||||||||||||||||
or GPS: . . . . . . . . . . . . | |||||||||||||||||||
County: . . . . . . . . . . . . | |||||||||||||||||||
PLEASE NOTE: | |||||||||||||||||||
The map is divided into 4 sections with each section divided into quarter-quarter sections. Please complete it by marking the appropriate section number(s) on the map and indicate as accurately as possible the location of the area treated. | |||||||||||||||||||
Section: . . . . . . . . . . . . | Section: . . . . . . . . . . . . | ||||||||||||||||||
Miscellaneous Information: | |||||||||||||||||||
AGR 4236 Pg. 2 |
INSTRUCTIONS |
Pesticide Application Record (Version 3) AGR 4236 (Rev. 4/07) |
1. Date may be spelled out or indicated numerically. |
2. Include first and last name. |
3. If the person's name is the same as No. 2, write "same" in the space for the licensed applicator's name and include the license number (if applicable) and telephone number. |
4. Check one. |
5. Indicate type of land or site treated, not location. Examples: Wheat, apples, rights of way, lawn, trees and shrubs, crawl space, wall voids, etc. |
6. May also be stated in terms such as linear feet or cubic feet. (Specify the term to which the number refers.) If spot treatment, write spot treatment. |
7. If the application was made under permit, but no permit number was issued, indicate the date the permit was issued. |
8.a) Brand name found on the pesticide label including adjuvants (buffer, spreader, sticker, surfactant, etc.). |
b) This number is found on the pesticide container label. If the material is being applied under a federal experimental use permit and no EPA Reg. No. exists, list the federal experimental use permit number. If the material is a spray adjuvant (buffer, spreader, sticker, surfactant, etc.) write "adjuvant" in this space and add the state registration number. |
c) Indicate the amount of pesticide formulation (product/adjuvant) applied to the total area listed on line 6. |
d) Other measures may include amount/sq. ft., amount/cu. ft., amount/linear ft., etc. |
e) This may be listed in various ways, such as: Amount of product/100 gallons water, percent formulation in the tank mix (i.e., 1%), gallons per acre of output volume, ppm (or other measure), or inches of water applied (chemigation). Specify the term to which the number refers. |
f) Depth of application (chemigation). |
9. Agricultural land includes such areas as forest lands and range lands. It does not include transportation and utility rights of way. |
10. List the date of application. |
11. Indicate first and last name(s). |
12. List license number(s) if applicable. |
13. This does not apply to private applicators or public agencies. |
14. Application start and stop times must be indicated. Indicate a.m. or p.m. |
15. The total of all entries in this column should equal the total listed on line 6. |
16. Indicate the direction from which the wind is blowing. Measure wind velocity in mph. If the wind varies in direction and velocity during the application, indicate the range of variance (i.e., S-SW 3-7 mph). Wind readings shall be obtained in close proximity to the application site. |
17. Indicate temperature in degrees Fahrenheit. (It may be indicated as the range encountered during the application.) Temperature readings shall be obtained in close proximity to the application site. |
State of Washington Department of Agriculture Olympia, Washington 98504 | PESTICIDE APPLICATION RECORD (Version 4) NOTE: This form must be completed same day as the application and it must be retained for 7 years (Ref. chapter 17.21 RCW) | |||||||||||||||||
A. | Date of Application - Year: . . . . . . . . . . . . | Month: . . . . . . . . . . . . | Day: . . . . . . . . . . . . | |||||||||||||||
B. | Firm Name: . . . . . . . . . . . . | Telephone No.: . . . . . . . . . . . . | ||||||||||||||||
Commercial Applicator's Name: . . . . . . . . . . . . | License No.: . . . . . . . . . . . . | |||||||||||||||||
Street Address: . . . . . . . . . . . . | City: . . . . . . . . . . . . | State: . . . . . . . . . . . . | Zip: . . . . . . . . . . . . | |||||||||||||||
C. | Name of person(s) who applied the pesticide: . . . . . . . . . . . . | |||||||||||||||||
License No(s): . . . . . . . . . . . . | ||||||||||||||||||
D. | Pesticide Information (list all information for each pesticide including spray adjuvants (buffer, surfactant, dye, etc.) in the tank mix): | |||||||||||||||||
Full Product Name | EPA Reg. No. | Concentration Amount: (Lbs., Qts., etc.) of brand per 100 gallons of tank mix. Amount and unit must be specified. | ||||||||||||||||
E. | Application crop or site: . . . . . . . . . . . . | F. | Apparatus License Plate No. . . . . . . . . . . . . | |||||||||||||||
G. | Record the following information for the specific conditions during each application: | |||||||||||||||||
CUSTOMER (a) full name (b) complete address | AMOUNT APPLIED (gals. of mix) | AREA TREATED (sq. ft., etc.) | START AND STOP TIME | TEMP F° | WIND DIR VEL (mph) | |||||||||||||
1. a) | ||||||||||||||||||
b) | ||||||||||||||||||
2. a) | ||||||||||||||||||
b) | ||||||||||||||||||
3. a) | ||||||||||||||||||
b) | ||||||||||||||||||
4. a) | ||||||||||||||||||
b) | ||||||||||||||||||
5. a) | ||||||||||||||||||
b) | ||||||||||||||||||
6. a) | ||||||||||||||||||
b) | ||||||||||||||||||
7. a) | ||||||||||||||||||
b) | ||||||||||||||||||
8. a) | ||||||||||||||||||
b) | ||||||||||||||||||
9. a) | ||||||||||||||||||
b) | ||||||||||||||||||
AGR 4234 (Rev. 4/07) |
INSTRUCTIONS |
Pesticide Application Record (Version 4) AGR 4234 (Rev. 4/07) |
This form may only be used for commercial residential ornamental and lawn applications. It may not be used to satisfy the application record requirements for agricultural employers. |
A. Date may be spelled out or indicated numerically. |
B. Include first and last name of the commercial applicator. |
C. Include first and last name(s). |
D. Product name: Brand name found on the pesticide label including adjuvants (buffer, spreader, sticker, surfactant, etc.). |
E. Indicate type of land treated, not location. Examples: Rights of way, lawn, trees and shrubs, driveways, etc. |
F. List the number of the license plate affixed to the apparatus. |
G. Customer's name and application information should be listed on line A. Street address should be listed on line B, including city. Additional pages may be added for additional customers on the same day, so long as the information in A through F remains the same. |
DAILY PESTICIDE APPLICATION RECORD (Version 5) For Commercial Pest Control Operators Only NOTE: This form must be completed same day as the application and retained for seven years (Ref. chapter 17.21 RCW) | ||||||||||||
A. | FIRM NAME AND ADDRESS: . . . . . . . . . . . . | |||||||||||
. . . . . . . . . . . . | TELEPHONE NUMBER: . . . . . . . . . . . . | |||||||||||
B. | APPLICATOR NAME: . . . . . . . . . . . . | LICENSE NO. . . . . . . . . . . . . | ||||||||||
C. | PERSON MAKING APPLICATION: . . . . . . . . . . . . | LICENSE NO. . . . . . . . . . . . . | ||||||||||
D. | DATE: . . . . . . . . . . . . | E. APPARATUS LICENSE NO: . . . . . . . . . . . . | ||||||||||
CUSTOMER (a) FULL NAME (b) FULL ADDRESS OR LOCATION OF APPLICATION (c) TARGET PEST | (a) EPA REG. NO./FULL PRODUCT NAME(S) (b) CONCENTRATION (c) TOTAL AMOUNT USED | (a) TIME (IN/OUT) (b) TEMP. (c) WIND DIR./ VELOCITY | APPLICATION SITE (C & C, SPOT, VOID, INJECTIONS, ETC.) | PESTICIDE APPLIED/ACRE OR OTHER MEASURE | ||||||||
1. a) | / | |||||||||||
b) | / | |||||||||||
c) | / | |||||||||||
2. a) | / | |||||||||||
b) | / | |||||||||||
c) | / | |||||||||||
3. a) | / | |||||||||||
b) | / | |||||||||||
c) | / | |||||||||||
4. a) | / | |||||||||||
b) | / | |||||||||||
c) | / | |||||||||||
5. a) | / | |||||||||||
b) | / | |||||||||||
c) | / | |||||||||||
6. a) | / | |||||||||||
b) | / | |||||||||||
c) | / | |||||||||||
7. a) | / | |||||||||||
b) | / | |||||||||||
c) | / | |||||||||||
AGR 4237 (Rev. 4/07) | OPTIONAL: MILEAGE START | MILEAGE END |
Wash. Admin. Code § 16-228-1320
Statutory Authority: Chapters 17.21, 15.58, and 34.05 RCW. 07-11-041A, § 16-228-1320, filed 5/9/07, effective 6/9/07; 03-22-029, § 16-228-1320, filed 10/28/03, effective 11/28/03. Statutory Authority: Chapters 15.58 and 17.21 RCW. 00-22-074, § 16-228-1320, filed 10/30/00, effective 11/30/00. Statutory Authority: Chapters 15.54, 15.58 and 17.21 RCW. 99-22-002, § 16-228-1320, filed 10/20/99, effective 11/20/99.