UNIVERSITY OF OREGON
|
NOTICE OF PESTICIDE USE
OR APPLICATION
|
Block A: Requester
Information:
|
Effective 4/29/03
|
Requested
By / Department
|
UO Contact / Department
|
Job
Number
|
Ticket
Number
|
IUC
|
Date
of
Request
|
Building
or Facility Name
|
|
Room
or Area
|
|
|
Target
Pest
|
|
|
|
Action
Level
|
|
Observed
Activity
|
Site
Description Circle:
Indoor /
Outdoor
|
General
Urban
|
Indoor/Outdoor
|
College/University
|
Location: Circle Public/
Private
|
Public
|
Private
|
Requested
Date of Use
|
|
|
Requested
Time
of Use
|
Purpose
of Use: Circle One
|
Insect
Control
|
Weed
Control
|
Rodent
Control
|
Bird
Control
|
Slug
Control
|
Plant
Growth
Regulator
|
Other
|
Notification
Instructionsstructions
|
Special
Precautions
|
Block
B: Applicator / User Information
|
|
Name
|
Phone
|
Address
|
|
|
|
Fax
|
|
|
|
Applicator
License Number
|
|
|
Email
|
|
|
|
Block
C: Pesticide Product and Pesticide Use
Reporting System Information
|
|
Pesticide
Product Name
|
EPA
Registration Number
|
UO
MSDS
Number
|
Date of
Use
|
Time of
Use
|
Amount
of Undiluted Pesticide Product Used
|
Method
of Application
|
Rate of Applicationation
|
|
|
|
|
Routing:
|
Tracking:
|
Initial
|
Date
|
1. Requester:
|
Complete
Block A (Forward
per Notification Instructions)
|
1. Requester (Optional)
|
________
|
___
/___ / ___
|
2.Applicator
/ User:
|
Complete Block B and C
|
2.
Applicator / User
|
________
|
___
/___ / ___
|
3. EHS:
|
For IPM
archiving / PURS
reporting
|
|
3. EHS
|
________
|
___
/___ / ___
|
|
|
|
|
EHS Fax:
|
541-346-7008
|
DPS
Fax:
|
541-346-0947
|
FS
Fax:
|
541-346-2299
|
|
|
PURS
Reporting By (Circle One):
University Contractor
|
Note: Shaded Areas Not Required for PURS Reporting
|
|
|
|
|
|
|
|
|