NISIMS Chemical Treatment Record Treatment Record ID _____________ LOCATION INFORMATION BLM Project Name Exact Location of Treatment Site: (ex:38.468218, -108.101364) State: County: BLM Office: TREATMENT INFORMATION Treatment Treatment Start Time End Time Date (ex: 0800) (ex: 1600) (ex: 6/1/2014) Temperature (F) Wind / Direction Humidity BLM PUP # Equipment Used TRUCK ATV UTV - BACKPACK AIRPLANE - HELICOPTER (circle – – – – HANDHELD SPRAYER WICK/WIPER MOWER TRACTOR (ex: WYP070-14-003-P) one) – – – – HORSEBACK SPRAYER Applicator Name Mix Diluent /license #/Role (circle one) WATER OIL - NONE – (ex: John Doe/14-001/ Applicator) Sprayer Calibration GALLONS/ACRE Distance to Water OUNCES/ACRE Rate (circle one) 0 TO 10 FEET - 10 TO 25 FEET (ex: 2 GALLONS/ACRE) (circle 25 TO 100 FEET - GT 100 FEET POUNDS/ACRE appropriate Rate) QUARTS/ACRE Delivery Method Total Acres Pattern AERIAL - GROUND BROADCAST - SPOT Treated (circle one) (circle one) (ex. 200) FOR SPOT APPLICATIONS ONLY Mix Amount Applied on Site (ex: 2 GALLONS) GALLONS CHEMICAL BRAND(s) APPLIED - In formulated product units CHEMICAL TRADE MANUFACTURER EPA REG # CHEMICAL RATE OF APPLICATION NAME (ex: MONSANTO, BASF) (ex: 524-475, COMMON NAME Liquid ex: 2 QUARTS PER ACRE, , 8 FLUID OUNCES PER (ex: Roundup 7969-150) ACRE, 1 PERCENT SOLUTION Pro, Overdrive) (ex: Glyphosate, Dicamba + Dry ex: 0.50 PER ACRE, 1 OUNCE PER ACRE Diflufenzopyr) ADJUVANTS BRAND(s) APPLIED - In formulated product units ADJUVANT MANUF RATE OF APPLICATION BRAND NAME (ex: HELENA Liquid ex: 2 QUARTS PER ACRE, , 8 OUNCES PER ACRE, 1 PERCENT SOLUTION CHEMICAL) Dry ex: 0.50 PER ACRE, 1 OUNCE PER ACRE (ex: DYNE_AMIC)
NISIMS Chemical Treatment Record Treatment Record ID _____________ LOCATION INFORMATION BLM Project Name Exact Location of Treatment Site: (ex:38.468218, -108.101364) State: County: BLM Office: TREATMENT INFORMATION Treatment Date (ex: 6/1/2014) Treatment Start Time (ex: 0800) End Time (ex: 1600) Temperature (F) Wind / Direction Humidity BLM PUP # (ex: WYP070-14-003-P) Equipment Used (circle one) TRUCK – ATV – UTV - BACKPACK – AIRPLANE - HELICOPTER – HANDHELD SPRAYER – WICK/WIPER – MOWER – TRACTOR – HORSEBACK SPRAYER Applicator Name /license #/Role (ex: John Doe/14-001/ Applicator) Mix Diluent (circle one) WATER – OIL - NONE Sprayer Calibration Rate (ex: 2 GALLONS/ACRE) (circle appropriate Rate) GALLONS/ACRE OUNCES/ACRE POUNDS/ACRE QUARTS/ACRE Distance to Water (circle one) 0 TO 10 FEET - 10 TO 25 FEET 25 TO 100 FEET - GT 100 FEET Delivery Method (circle one) AERIAL - GROUND Pattern (circle one) BROADCAST - SPOT Total Acres Treated (ex. 200) FOR SPOT APPLICATIONS ONLY Mix Amount Applied on Site (ex: 2 GALLONS) GALLONS CHEMICAL BRAND(s) APPLIED - In formulated product units CHEMICAL TRADE NAME (ex: Roundup Pro, Overdrive) MANUFACTURER (ex: MONSANTO, BASF) EPA REG # (ex: 524-475, 7969-150) CHEMICAL COMMON NAME (ex: Glyphosate, Dicamba + Diflufenzopyr) RATE OF APPLICATION Liquid ex: 2 QUARTS PER ACRE, , 8 FLUID OUNCES PER ACRE, 1 PERCENT SOLUTION Dry ex: 0.50 PER ACRE, 1 OUNCE PER ACRE ADJUVANTS BRAND(s) APPLIED - In formulated product units ADJUVANT BRAND NAME (ex: DYNE_AMIC) MANUF (ex: HELENA CHEMICAL) RATE OF APPLICATION Liquid ex: 2 QUARTS PER ACRE, , 8 OUNCES PER ACRE, 1 PERCENT SOLUTION Dry ex: 0.50 PER ACRE, 1 OUNCE PER ACRE