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16-228-1300  <<  16-228-1320 >>   16-228-1322

WAC 16-228-1320

Agency filings affecting this section

What are the recordkeeping requirements for pesticide applicators?

(1) Certified applicators and all persons applying pesticides to more than one acre of agricultural land in a calendar year including public entities engaged in roadside spraying, and all persons making landscape applications of pesticides to types of property listed in RCW 17.21.410 (1), (b), (c), (d) and (e) shall keep records for each application which shall include the following:
(a) The full name and full address of the person for whom the pesticide was applied.
(b) The address or exact location of the land where the pesticide was applied. If the application is made to one acre or more of agricultural land, the field must be located on the map on the adopted form. Location of agricultural land shall be made using section, township and range, geographical positioning system coordinates, or by irrigation block and farm unit numbers.
(c) The year, month, day and start and stop time the pesticide was applied.
(d) The product name used on the registered label and the United States Environmental Protection Agency registration number, if applicable, of the pesticide which was applied.
(e) The direction from which the wind is blowing and estimated velocity of the wind in miles per hour (mph) and the temperature in degrees Fahrenheit at the time the pesticide was applied: Provided that this subsection (e) shall not apply to applications of baits in bait stations, pesticide applications within structures and drip or subsurface irrigation applications. Wind and temperature readings shall be obtained in close proximity to the application site.
(f) The total amount of pesticide applied such as pounds, gallons, ounces, etc.
(g) The amount of pesticide applied per acre or one thousand square feet or other appropriate measure.
(i) For PCO classification or residential ornamental applications, the amount shall be recorded to the nearest ounce of product or to the nearest gallon of liquid spray per site.
(ii) Fumigation records shall include the pounds of gas released per one thousand cubic feet of space, the temperature, and the duration of the exposure period.
(h) The concentration of pesticide that was applied. Liquid applications may be recorded as, but are not limited to, amount of product per one hundred gallons of liquid spray, gallons per acre of output volume, ppm, percent product in tank mix (e.g., 1%). For chemigation applications record "inches of water applied" or other appropriate measure.
(i) The pests to be controlled (for PCO classification only).
(j) Specific crop or site to which pesticide was applied.
(k) Apparatus license plate number.
(l) The licensed applicator's full name, certified pesticide applicator license number, complete address, telephone number, and the full name of the individual or individuals making the application.
(m) The number of acres or other appropriate measure to which the pesticide was applied.
(n) For commercial applications, the full name and complete address of the commercial firm.
(2) Application records shall be completed and available to the department the same day the pesticides were applied.
(3) Application records shall be kept for a period of seven years from the date of the application of the pesticide to which such records refer. The director shall, upon request in writing, be furnished with a copy of such records immediately by the licensee.
(4) Upon written request, the applicator shall provide the customer with a record of each application of pesticides to his/her land, for the current season, which shall contain the information listed in WAC 16-228-1320(1).
(5) Except as stated in subsection (6) of this section, the information required in subsection (1) of this section shall be provided upon request on the appropriate page of the pesticide record form (figures 1-8): Provided that computerized records may be maintained as long as the records can be produced in the form and format prescribed by the department.
(6) The department may allow by written permit the information required in subsection (1) of this section to be kept in a different form and format than that described in figures 1-8: Provided that the following criteria are met:
(a) The pesticide application recordkeeping system is computerized;
(b) The pesticide application recordkeeping system contains all the information required by subsection (1) of this section, and can be produced in a form and format acceptable to the department.
(7) All apparatus shall be kept in good repair and only that apparatus capable of performing all functions necessary to ensure proper and thorough application of pesticides shall be used. Apparatus shall be cleaned so that no residue remains which may cause injury to land, humans, desirable plants and animals, from subsequent applications.
(8) On demand of the director, the applicator shall make immediately available for inspection the pesticides being applied and the apparatus used for the application: Provided that this inspection is made at the site of application or where the apparatus is located.
(9) The applicator shall make available necessary safety equipment in proper working order and advise employees on its use to meet the safety requirements of the pesticide label.
(10) Maintain a uniform mixture at all times in operating apparatus when applying pesticides.
(11) All containers used for pesticide mixtures, other than those in an apparatus, shall have a label identifying the contents as a pesticide, the active ingredient, and appropriate restrictions and precautions.
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: . . . .
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
One
Mile
 
 
 
N
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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) . . . .
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Section(s): . . . .
 
 
 
 
 
 
 
 
 
 
 
One
Mile
 
Block: . . . .
Farm Unit: . . . .
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
or GPS: . . . .
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
County: . . . .
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
N
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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: . . . .
 
 
 
 
 
 
 
 
 
 
Township: . . . .
N
 
 
 
 
 
 
 
 
 
 
 
 
 
Range: E OR W (please indicate): . . . .
 
 
 
 
 
 
 
 
 
 
One
Mile
 
Section(s): . . . .
 
N
 
 
 
 
 
 
 
 
 
 
 
 
 
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
 
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)
MILEAGE STARToptional:
MILEAGE END
 
 
 
 
 
 
[Statutory Authority: Chapters 17.21, 15.58, and 34.05 RCW. WSR 07-11-041A, § 16-228-1320, filed 5/9/07, effective 6/9/07; WSR 03-22-029, § 16-228-1320, filed 10/28/03, effective 11/28/03. Statutory Authority: Chapters 15.58 and 17.21 RCW. WSR 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. WSR 99-22-002, § 16-228-1320, filed 10/20/99, effective 11/20/99.]