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HERBICIDE APPL1CATION/USAGE REPORT
Agency:
-Please Select-
Report Data Provided By:
Report Data Entered By:
Date:
1
HERBICIDE TRACKING REPORT
Agency: DPW Highways
Report Data Provided By:
Report Data Entered By:
Date:
Start Time: End Time:
CREW
Equipment Number(Truck#):
Supervisor Name:
Driver Name:
Sprayer Name:
PPE Used:
❑ Boots/Shoes n Respirator(Full-Face)
❑ Long Pants ❑ Respirator(Half-Face)
❑ Long Sleeve Shirt ❑ Safety Glasses
❑ Gloves ❑ Face Shield
❑ Coveralls ❑ Other- Please Specify
LOCATION INFORMATION
Map Location:
(Describe the location of spraying)
Location Name/Street Name:
Location Type:
❑ Drainageway ❑ Road Median
❑ Roadside Shoulder ❑ Other- Provide Description
❑ Roadside Sidewalk
Expected Public Exposure:
(What is the expected public exposure at this location)
❑ Low (Fence, Perimeter, Roadside)
❑ Moderate (Sidewalk, Non-Recreational Grounds)
❑ High (Playfield)
Length Completed (ft):
PRECAUTIONS
Weather Conditions:
❑ Sunny/Clear ❑ Light Rain/Drizzle
n Partly Cloudy n Rain
❑ Overcast ❑ Other- Provide Description
Anemometer(Model or COH Inventory#):
Wind Speed (MPH):
Wind Conditions:
❑ Consistent Speed + Consistent Direction
❑ Variable Speed + Consistent Direction
❑ Variable Speed +Variable Direction
Temperature (F):
Relative Humidity(%):
Ground Surface Conditions:
❑ Dry ❑ Wet
❑ Damp ❑ Dewy
Notice Posted:
Yes ❑ No
Date:
Restricted Access:
❑ No ❑ Other- Provide Description
❑ Until Dry
How long was the herbicide-treated area secured from access after completion of
application (Hours):
Did anyone enter the restricted area:
❑ Yes ❑ No
Did it rain before herbicide completely dried:
• Yes ❑ No
HERBICIDE
Herbicide Purpose:
❑ General Weed Control ❑ Selective Treatment
n Invasive Species Eradication n O• ther- Provide Description
HERBICIDE APPLICATION
Herbicide Name:
❑ Round Up Pro Concentrate ❑ Finale
❑ Aquamaster ❑ Diuron 4L
❑ Milestone ❑ Garlon 4
❑ Confront ❑ Clean Amine
❑ Celsius WG ❑ Other- Provide Description
Gallons of water used:
Concentration (%) of prepared solution:
Additive/Adjutants Added:
❑ Yes n N• o
Product Name:
Concentration (%):
Dye/Marker Used:
❑ Yes ❑ No
Product Name:
Concentration (%):
Was entirety of prepared solution applied:
❑ Yes ❑ No- Complete next two questions
Explain why the prepared solution was not all applied:
Describe what was done with the remaining solution:
*If more than one herbicide was applied to the area please fill out another
form - HERBICIDE APPLICTION section only
ADDITIONAL INFORMATION
Task Completed:
❑ Yes ❑ N• o
Issues Encountered:
Notes:
HERBICIDE TRACKING REPORT
Agency:
Division/Section:
Report Data Provided By:
Report Data Entered By:
Date:
Start Time: End Time:
CREW
Applicator:
PPE Used:
❑ Boots/Shoes ❑ Respirator(Full-Face)
❑ Long Pants ❑ Respirator(Half-Face)
❑ Long Sleeve Shirt ❑ Safety Glasses
❑ Gloves ❑ Face Shield
❑ Coveralls ❑ Other- Please Specify
Application Equipment Used:
(Type,Model, Capacity,etc)
Direct Supervisor (On day of application):
Supervisor:
LOCATION INFORMATION
Map Location:
(Describe the location of spraying)
Park/Facility/Site Name:
Expected Public Exposure:
(What is the expected public exposure at this location)
❑ Low (Fence, Perimeter, Roadside)
❑ Moderate (Sidewalk, Non-Recreational Grounds)
❑ High (Playfield)
PRECAUTIONS
Weather Conditions:
❑ Sunny/Clear ❑ Light Rain/Drizzle
❑ Partly Cloudy ❑ Rain
❑ Overcast ❑ Other- Provide Description
Anemometer(Model or COH Inventory#):
Wind Speed (MPH):
Wind Conditions:
❑ Consistent Speed + Consistent Direction
❑ V• ariable Speed + Consistent Direction
❑ Variable Speed +Variable Direction
Temperature (F):
Relative Humidity(%):
Ground Surface Conditions:
n D• ry ❑ Wet
❑ D• amp ❑ Dewy
Notice Posted:
❑ Yes ❑ No
Date:
Restricted Access:
(Describe how access by the public was restricted)
❑ Entire Park Closed Off ❑ Applicator Remained in Area for Duration
❑ Area Fenced Off ❑ Other- Provide Description
❑ S• ecurity Personnel Posted
How long was the herbicide-treated area secured from access after completion of
application (Hours):
Did anyone enter the restricted area:
❑ Yes ❑ No
Did it rain before herbicide completely dried:
❑ Yes ❑ No
HERBICIDE
Herbicide Purpose:
❑ General Weed Control ❑ Selective Treatment
❑ Invasive Species Eradication ❑ Other- Provide Description
HERBICIDE APPLICATION
Herbicide Name:
❑ Round Up Pro Concentrate ❑ Finale
❑ Aquamaster ❑ Diuron 4L
❑ Milestone ❑ G• arlon 4
❑ Confront ❑ C• lean Amine
❑ Celsius WG n O• ther- Provide Description
Gallons of water used:
Concentration (%) of prepared solution:
Additive/Adjutants Added:
❑ Yes ❑ No
Product Name:
Concentration (%):
Dye/Marker Used:
❑ Yes ❑ No
Product Name:
Concentration (%):
Was entirety of prepared solution applied:
❑ Yes ❑ No - Complete next two questions
Explain why the prepared solution was not all applied:
Describe what was done with the remaining solution:
*If more than one herbicide was applied to the area please fill out another
form - HERBICIDE APPLICTION section only
ADDITIONAL INFORMATION
Task Completed:
❑ Yes ❑ No
Issues Encountered:
Notes:
HERBICIDE TRACKING REPORT
Agency: Parks and Recreation
Division/Section:
❑ Parks Maintenance ❑ Pana'ewa Zoo and Equestrian
❑ Municiple Golf Course ❑ Elderly Activities
❑ Recreation/Ho'olulu ❑ Administration/Other
Report Data Provided By:
Report Data Entered By:
Date:
Start Time: End Time:
CREW
Applicator:
PPE Used:
❑ Boots/Shoes ❑ Respirator (Full-Face)
❑ Long Pants ❑ Respirator(Half-Face)
❑ Long Sleeve Shirt ❑ Safety Glasses
❑ Gloves ❑ Face Shield
❑ Coveralls ❑ Other- Please Specify
Application Equipment Used:
(Type, Model, Capacity,etc)
Direct Supervisor(On day of application):
Supervisor:
LOCATION INFORMATION
Map Location:
(Describe the location of spraying)
Park/Facility/Site Name:
Expected Public Exposure:
(What is the expected public exposure at this location)
❑ Low(Fence, Perimeter, Roadside)
❑ Moderate (Sidewalk, Non-Recreational Grounds)
❑ High (Playfield)
PRECAUTIONS
Weather Conditions:
❑ Sunny/Clear ❑ Light Rain/Drizzle
❑ Partly Cloudy n Rain
❑ Overcast ❑ Other- Provide Description
Anemometer (Model or COH Inventory It):
Wind Speed (MPH):
Wind Conditions:
❑ Consistent Speed + Consistent Direction
❑ Variable Speed + Consistent Direction
❑ Variable Speed +Variable Direction
Temperature (F):
Relative Humidity(%):
Ground Surface Conditions:
❑ Dry ❑ Wet
❑ Damp ❑ Dewy
Notice Posted:
❑ Yes ❑ No
Date:
Restricted Access:
(Describe how access by the public was restricted)
❑ Entire Park Closed Off ❑ A• pplicator Remained in Area for Duration
❑ Area Fenced Off ❑ O• ther- Provide Description
❑ Security Personnel Posted
How long was the herbicide-treated area secured from access after completion of
application (Hours):
Did anyone enter the restricted area:
❑ Yes n No
Did it rain before herbicide completely dried:
▪ Yes ❑ No
HERBICIDE
Herbicide Purpose:
❑ General Weed Control n Selective Treatment
❑ Invasive Species Eradication [l Other- Provide Description
HERBICIDE APPLICATION
Herbicide Name:
❑ Round Up Pro Concentrate ❑ Finale
❑ Aquamaster ❑ Diuron 4L
❑ Milestone ❑ Garlon 4
❑ Confront ❑ Clean Amine
❑ Celsius WG ❑ Other- Provide Description
Gallons of water used:
Concentration (%) of prepared solution:
Additive/Adjutants Added:
❑ Yes ❑ No
Product Name:
Concentration (%):
Dye/Marker Used:
❑ Yes ❑ No
Product Name:
Concentration (%):
Was entirety of prepared solution applied:
❑ Yes ❑ No - Complete next two questions
Explain why the prepared solution was not all applied:
Describe what was done with the remaining solution:
*If more than one herbicide was applied to the area please fill out another
form - HERBICIDE APPLICTION section only
ADDITIONAL INFORMATION
Task Completed:
❑ Yes ❑ No
Issues Encountered:
Notes: