Pesticide Application Record Sheet

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					                                     Pesticide Application Record Sheet


LANDOWNER: ________________________                       DATE AND TIME: _________________



APPLICATOR: _________________________

ADDRESS: ____________________________________________________________________

______________________________________________________________________________

LOCATION OFAPPLICATION: (attach map) ________________________________________

______________________________________________________________________________

TARGET PEST SPECIES: ________________________________________________________

TOTAL AREA TREATED: _______________________________________________________

DISCRIPTION OF TREATED AREA :(pine forest, hardwood forest, open ag. field, etc)
______________________________________________________________________________

PESTICIDE USED AND APPLICATION RATE: _____________________________________

TYPE OF EQUIPMENT USED: ___________________________________________________

WEATHER:
      WIND SPEED: ______________             WIND DIRECTION: _______________________
                                             TEMPERATURE: __________________________
                                             HUMIDITY: ______________________________
                                             SOIL: wet ___ moist ___ dry ___

UNEXPECTED OCCURANCES AND ACTIONS TAKEN:



NAMES, CONCENTRATIONS AND QUANTITIES OF PESTICIDES DISPOSED AND
MANNER OF DISPOSITION:



                          An Equal Opportunity Employer and Service Provider