In the realm of agricultural practices, particularly where pesticide application is concerned, meticulous record-keeping is not just advisable; it's mandated by law. The State of Washington Department of Agriculture provides a mechanism for this through the AGR 4226 form, an essential document for anyone applying pesticides. This form, required to be completed on the same day as the pesticide application, serves multiple crucial functions. It chronicles comprehensive details such as the date and time of application, the person for whom the pesticides were applied, the licensed applicator's information, and specifics about the pesticides used, including product names and amounts. Additionally, the form captures the application's geographical details, weather conditions at the time of application, and the method of application, offering a holistic view of the pesticide usage scenario. Significantly, it demands attention to the longevity of these records, prescribing a seven-year retention period as stipulated by chapter 17.21 RCW. This meticulous documentation helps in ensuring compliance with regulations, aids in the monitoring of pesticide use, and enhances the safety of agricultural practices by providing traceable records that can be audited or reviewed in the event of environmental or health concerns.
| Question | Answer |
|---|---|
| Form Name | Form Agr 4226 |
| Form Length | 3 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 45 sec |
| Other names | adjuvants, Washington, Applicator, RCW |
State of Washington
Department of Agriculture
Olympia, Washington 98504
PESTICIDE APPLICATION RECORD (Version 1)
NOTE: This form must be completed same day as the application and it must be retained for 7 years (Ref. chapter 17.21 RCW)
1. Date of Application - Year: |
Month: |
Day: |
Start Time: |
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Stop Time: |
2.Name of Person for whom the pesticide was applied:
Firm Name (if applicable): .............................................................................................................................................................
Street Address: ..............................................................................................................................................................................................................................................................................................
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................................................................................. |
City: |
State: |
................... Zip: |
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3. |
Licensed Applicator’s Name (if different from #2 above): |
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License No |
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Firm Name (if applicable): |
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Tel. No.: |
Street Address: |
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.................................................................................. |
City: |
State: |
.................... Zip: |
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4. |
Name of person(s) who applied the pesticide (if different from #3 above): |
................................................................................... |
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............................................................... |
License No(s). if applicable: |
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5. |
Application Crop or Site: |
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6. |
Total Area Treated (acre, sq. ft., etc.): |
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7. |
Was this application made as a result of a WSDA Permit? |
No |
Yes (if yes, give Permit No.) # |
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8. Pesticide Information (please list all information for each pesticide, including adjuvants (buffer, surfactant, etc.), in the tank mix):
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c) Total Amount of |
d) Pesticide |
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Pesticide Applied |
Applied/Acre |
e) Concentration |
a) Full Product Name |
b) EPA Reg. No. |
in Area Treated |
(or other measure) |
Applied |
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/
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9.Address or exact location of application. NOTE: If the application is made to one acre or more of agricultural land, the field location must be shown on the map on page two of this form.
10.Wind direction and estimated velocity (mph) during the application: ...........................................................................................
11.Temperature during the application:.............................................................................................................................................
12.Apparatus license plate number (if applicable): ...........................................................................................................................
13. Air Ground Chemigation
14. Depth of application / inches of water (chemigation): ...................................................................................................................
15. Miscellaneous information:
Form AGR 4226 (Rev. 5/03)
Location of Application: If the application covers more than one township or range, please indicate the township & range for the top left section of the map only:
Township: |
N |
Range: E OR W (please indicate) |
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Section(s): |
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Block: |
Farm Unit:: |
or GPS: |
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County: |
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PLEASE NOTE:
The map is divided into 4 sections with each section divided into
Section: |
Section: |
N
Section: |
Section: |
Miscellaneous Information:
One Mile
Form AGR 4226 (Rev. 5/03) Pg. 2
INSTRUCTIONS
Pesticide Application Record (Version 1) AGR 4226 (Rev. 5/03)
1.Date may be spelled out or indicated numerically. Time must be indicated as start and stop times.
2.Include first and last name.
3.If the person’s name is the same as No. 2, please write “same” in the space for the licensed applicator’s name and include the license number (if applicable) and telephone number.
4.Include first and last name(s).
5.Indicate type of land or site treated, not location. Examples: Wheat, apples, rights of way, lawn, trees and shrubs, crawl space, wall voids, etc.
6.May also be stated in terms such as linear feet, cubic feet, etc. (Specify the term to which the number refers.) If spot treatment, write spot treatment.
7.If the application was made under permit, but no permit number was issued, indicate the date the permit was issued.
8.a. Brand name found on the pesticide label including adjuvants (buffer, surfactant, dye, etc.).
b.This number is found on the pesticide container label. If the material is being applied under a federal experimen- tal use permit and no EPA Reg. No. exists, list the federal experimental use permit number. If the material is a spray adjuvant (buffer, spreader, sticker, etc.) write “adjuvant” in this space.
c.Indicate the amount of pesticide formulation (product) applied to the total area listed on line 6.
d.Other measures may include amount/sq. ft., amount/cu. ft., amount/linear ft., etc.
e.This may be listed in various ways, such as: Amount of product/100 gallons water, percent formulation in the tank mix (i.e. 1%), gallons per acre of output volume, ppm (or other measure), or inches of water applied (chemigation). Specify the term to which the number refers.
9.Agricultural land includes such areas as forest lands and range lands. It does not include transportation and utility rights of way.
10.Indicate the direction from which the wind is blowing. Measure wind velocity in mph. If the wind varies in direc- tion and velocity during the application, indicate the range of variance (i.e.
11.Indicate temperature in degrees Fahrenheit. (It may be indicated as the range encountered during application.) Temperature readings shall be obtained in close proximity to the application site.
12.This does not apply to private applicators or public agencies.
13.Check one.
14.Depth of application/inches of water (chemigation).
15.This space is available for any additional information you may wish to include.
Form AGR 4226 (Rev. 5/03) Pg. 3