Agr Form 640 4234 – Fill Out and Use This PDF

The AGR Form 640-4234 is the Washington State Department of Agriculture pesticide application record for commercial residential ornamental and lawn treatments. Chapter 17.21 RCW requires applicators to complete this form on the day of each pesticide application and retain records for seven years. Use the FormsPal editor to fill out, download, and print your completed AGR Form 640-4234 online.

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Agr Form 640 4234 PDF Details

The AGR Form 640-4234 is the official Washington State Department of Agriculture pesticide application record. It was developed by the WSDA Pesticide Management Division to standardize recordkeeping for commercial residential ornamental and lawn applicators across the state.

Washington State law under chapter 17.21 RCW requires applicators to complete this form on the same day as each pesticide application. Records must be retained for a minimum of seven years. WSDA inspectors may request access to these records at any time during that period.

The form collects the following information for each application: the date, the name and license number of the commercial applicator, the pesticide product name and EPA registration number, the active ingredient and concentration, and the total amount applied. It also captures environmental conditions including wind speed, wind direction, and air temperature at the time of application, along with the address and size of the treated area.

Maintaining accurate records on this form protects applicators in the event of an inspection or complaint. It also supports public and environmental safety by creating a verifiable record of what pesticide was used and under what conditions. For related Washington State agricultural recordkeeping, see the AGR Form 702-4279 and the WSDA Form Record.

Question	Answer
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

Form Preview Example

		Washington State Department of Agriculture
PESTICIDE APPLICATION RECORD (Version 4)			Pesticide Management Division
PESTICIDE APPLICATION RECORD (Version 4)			PO Box 42560
	NOTE: This form must be completed same day as the application		Olympia WA 98504-2560
			(877) 301-4555
	and it must be retained for 7 years (Ref. chapter 17.21 RCW)		(877) 301-4555

A. Date of Application - Year:	Month:	Day:
B. Firm Name:		Telephone No.:
Commercial Applicator's Name:		License No.:
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):

		Concentration
Full Product Name	EPA Reg. No.	Amount: (Lbs., Qts., etc.) of brand per 100 gallons
		of tank mix. Amount and unit must be specified.

E. Application crop or site:

F. Apparatus License Plate No.

G. Record the following information for the specific conditions during each application:

			START			WIND
			START
CUSTOMER	AMOUNT APPLIED	AREA TREATED	& STOP	TEMP		VEL
(a) full name (b) complete address	(gals. of mix)	(sq. ft., etc.)	TIME	Fo	DIR	(mph)

1.a)

2.a)

3.a)

4.a)

5.a)

6.a)

7.a)

8.a)

9.a)

AGR FORM 640-4234 (R/4/07)

INSTRUCTIONS

Pesticide Application Record (Version 4) AGR FORM 640-4234 (R/4/07)

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.

How to Edit Agr Form 640 4234 Online for Free

The AGR Form 640-4234 is a two-page pesticide application record. Use the steps below to complete it accurately using the FormsPal online editor.

Step 1: Enter the Date and Applicator Information

Record the exact date the pesticide was applied. Enter the commercial applicator's full name, Washington State license number, and business name. State law requires this information to be recorded on the day of application, not retroactively.

Step 2: Identify the Pesticide Product

Write the product name and EPA registration number from the pesticide label. List the active ingredient and its concentration percentage. Record the total amount applied in the appropriate unit: fluid ounces, gallons, or pounds.

Step 3: Describe the Application Site

Enter the address of the property where the pesticide was applied. Identify the treatment area type: lawn, ornamental, or other. Record the total size of the treated area in square feet or acres.

Step 4: Record Environmental Conditions

Log the wind speed in miles per hour and the wind direction at the time of application. Record the air temperature in degrees Fahrenheit. These conditions are required by WSDA and may be reviewed during inspections.

Step 5: Sign and Store the Completed Form

The commercial applicator must sign the completed AGR Form 640-4234. Keep the signed record on file for at least seven years. Make the record available to WSDA inspectors upon request.

Frequently Asked Questions

Who must complete the AGR Form 640-4234?
Commercial applicators performing pesticide applications for residential ornamental and lawn sites in Washington State are required to complete this form.

How long must records be kept?
Records must be retained for a minimum of seven years as required by chapter 17.21 RCW.

Can the form be completed online?
Yes. The FormsPal editor allows you to complete, download, and print the AGR Form 640-4234 from any browser. No software installation is required.

What happens if a record is incomplete or missing?
WSDA can issue a citation for incomplete or missing pesticide application records. Penalties may include fines or license suspension under Washington State regulations.