In the realm of agricultural and residential pesticide applications, meticulous records are vital, not only for regulatory compliance but also for ensuring the safety and effectiveness of pesticide use. At the heart of this record-keeping process in Washington State stands the Agr 640 4234 form, a crucial document crafted by the Washington State Department of Agriculture's Pesticide Management Division. This form, explicitly designed for commercial residential ornamental and lawn applications, serves a multifaceted purpose: it is a testament to the application’s adherence to the stringent standards set forth under chapter 17.21 RCW, requiring completion on the same day as the pesticide application and preservation for a period of seven years thereafter. Detailing everything from the date of application and information about the commercial applicator, to the specifics of the pesticide used including concentration and the total amount, the form embodies a comprehensive approach to pesticide application documentation. Notably, it extends beyond mere product usage, capturing the application's environmental conditions such as wind speed and direction, temperature, and the specific area treated, thereby providing an extensive narrative of each pesticide application's circumstances. This depth of detail ensures that the information is not just a formality but a critical tool in assessing and improving the application practices for safety and environmental protection.
| Question | Answer |
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| Form Name | Agr Form 640 4234 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | Qts, adjuvants, AGR, agr form 640 4234 |
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Washington State Department of Agriculture |
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PESTICIDE APPLICATION RECORD (Version 4) |
Pesticide Management Division |
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PO Box 42560 |
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NOTE: This form must be completed same day as the application |
Olympia WA |
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(877) |
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and it must be retained for 7 years (Ref. chapter 17.21 RCW) |
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A. Date of Application - Year: |
Month: |
Day: |
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B. Firm Name: |
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Telephone No.: |
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Commercial Applicator's Name: |
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License No.: |
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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):
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Concentration |
Full Product Name |
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EPA Reg. No. |
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Amount: (Lbs., Qts., etc.) of brand per 100 gallons |
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of tank mix. Amount and unit must be specified. |
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E. Application crop or site: |
F. Apparatus License Plate No. |
G. Record the following information for the specific conditions during each application:
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START |
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WIND |
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CUSTOMER |
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AMOUNT APPLIED |
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AREA TREATED |
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& STOP |
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TEMP |
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VEL |
(a) full name (b) complete address |
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(gals. of mix) |
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(sq. ft., etc.) |
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TIME |
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Fo |
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DIR |
(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 FORM
INSTRUCTIONS
Pesticide Application Record (Version 4) AGR FORM
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.