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Sample pesticide application record location of Application


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Sample PESTICIDE APPLICATION RECORD





Location of Application

Pesticide Product Used

Mixture Recipe per Product Label

Total Volume Applied
Total Volumen Aplicar

Date (M/D/Y)

& Time (am/.pm)


Applicator Full Name/

Pesticide License or Handler Number


Farm Name & Address;

City or Township;

and County of Application


Field

Name
Sitio Aplicado


Acres Treated/ Tratado



Crop Treated

Cosech


Tratado

Brand Name of Pesticide
Nombre del

Pesticida



EPA

Registration Number


Numero de

Registracion EPA



Active Ingredient(s)

Ingrediente

Acitvo


Amount of Pesticide Concentrate used before mixing*

Total Diluent
Candidad

Usada


Date/Time Application Completed


Fecha y

Hora de la

Aplicacion


Date/Time of Reentry
Fecha y

Hora de


Reentrada

XYZ Farm

1234 Farm Road;

Agriville; Cucumberland County


G-11

8

Tomatoes

VydateL

352-372

Oxamyl

12 qts.

400 gal

200 gal

6/15/10- 9:30 am

6/17/10-9:30 am

John Smith

C080569



PESTICIDE APPLICATION RECORD


Location of Application

Pesticide Product Used

Mixture Recipe per Product Label

Total Volume Applied
Total Volumen Aplicar

Date (M/D/Y)

& Time (am/.pm)


Applicator Full Name/

Pesticide License or Handler Number


Farm Name & Address;

City or Township;

and County of Application


Field

Name
Sitio Aplicado


Acres Treated/ Tratado



Crop Treated

Cosech


Tratado

Brand Name of Pesticide
Nombre del

Pesticida



EPA

Registration Number


Numero de

Registracion EPA



Active Ingredient(s)

Ingrediente

Acitvo


Amount of Pesticide Concentrate used before mixing*

Total Diluent
Candidad

Usada


Date/Time Application Completed


Fecha y

Hora de la

Aplicacion


Date/Time of Reentry
Fecha y

Hora de


Reentrada










































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