The Washington State Department of Agriculture (WSDA) Pesticide Application Record, now in version 3, is a meticulous form designed to standardize and ensure the comprehensive documentation of pesticide applications within the state. This form, which is an essential component of the Pesticide Management Division's oversight, stipulates that all details of any pesticide application must be diligently recorded on the same day the application occurs. It emphasizes transparency and accountability by requiring detailed inputs such as the date of application, information about the person for whom and by whom the pesticide was applied, specifics of the pesticide, including total amount and concentration applied, and the exact location of application. Notably, the form also demands a mapping for applications covering agricultural land exceeding one acre, and it introduces protocols for indicating the start and stop times of the application, environmental conditions such as wind direction and velocity, and the temperature during application. The necessity to keep these records for a duration of seven years, as referenced in chapter 17.21 of the Revised Code of Washington (RCW), underscores the seriousness with which the state approaches pesticide management, safeguarding both environmental and public health. Besides its immediate utility in tracking and managing pesticide use, this documentation facilitates a long-term analytical perspective on pesticide applications and their implications across the state, thereby supporting efforts towards sustainable agricultural practices and environmental stewardship.
| Question | Answer |
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| Form Name | Wsda Form Record |
| Form Length | 3 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 45 sec |
| Other names | wsda spray records fillable, wsda form pesticide record, wa agr form pesticide, wsda spray record version 1 |
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Washington State Department of Agriculture |
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PESTICIDE APPLICATION RECORD (Version 3) |
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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and it must be retained for 7 years (Ref. chapter 17.21 RCW) |
(877) |
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1. Date of Application - Year: |
Month: |
Day(s): |
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2. Name of person for whom the pesticide was applied:
Firm Name (if applicable):
Street Address: |
City: |
State: |
Zip: |
3. Licensed Applicator's Name (if different from #2 above): |
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License No.: |
Firm Name (if applicable): |
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Tel. No.: |
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Street Address: |
City: |
State: |
Zip: |
4.
Air
Ground
Chemigation
5.Application Crop or Site:
6.Total Area Treated (acre. sq. ft., etc.):
7.Was this application made as a result of a WSDA Permit?
No
Yes (If yes, give Permit No.) #
8. Pesticide Information (list all information for each pesticide including adjuvants in the tank mix):
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c) Total Amount of |
d) Pesticide |
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f) Depth of |
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Pesticide Applied |
Applied/Acre |
e) Concentration |
Application |
a) Full Product Name |
b) EPA Reg. No. |
in Area Treated |
(or other measure) |
Applied |
(Chemigation) |
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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. Date
11. Name of person(s) making the application
12.13. Apparatus
License No. |
Lic. Plate No. |
14.Time
Start Stop
15.Acres Completed
16. Wind
Dir. |
Vel.(mph) |
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17. Temp
AGR FORM
10. Date
11. Name of person(s) making the application
12. |
13. Apparatus |
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14. Time |
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License No. |
Lic. Plate No. |
Start |
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Stop |
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15.Acres Completed
16. Wind
Dir. |
Vel.(mph) |
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17. Temp
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 |
W (please indicate) |
Section(s): |
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Block: |
Farm Unit: |
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or GPS:
County:
PLEASE NOTE:
The map is divided into 4 sections with each section divided into
Miscellaneous Information:
Section: |
Section: |
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One |
Mile |
N |
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Section: |
Section: |
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AGR FORM
INSTRUCTIONS
Pesticide Application Record (Version 3) AGR FORM
1.Date may be spelled out or indicated numerically.
2.Include first and last name.
3.If the person's name is the same as No. 2, write "same" in the space for the licensed applicator's name and include the license number (if applicable) and telephone number.
4.Check one.
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 or cubic feet. (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, spreader, sticker, surfactant, etc.).
b)This number is found on the pesticide container label. If the material is being applied under a federal experimental 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, surfactant, etc.) write "adjuvant" in this space and add the state registration number.
c)Indicate the amount of pesticide formulation (product/adjuvant) 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.
f)Depth of application (chemigation).
9.Agricultural land includes such areas as forest lands and range lands. It does not include transportation and utility rights of way.
10.List the date of application.
11.Indicate first and last name(s).
12.List license number(s) if applicable.
13.This does not apply to private applicators or public agencies.
14.Application start and stop times must be indicated. Indicate a.m. or p.m.
15.The total of all entries in this column should equal the total listed on line 6.
16.Indicate the direction from which the wind is blowing. Measure wind velocity in mph. If the wind varies in direction and velocity during the application, indicate the range of variance (i.e.,
17.Indicate temperature in degrees Fahrenheit. (It may be indicated as the range encountered during the application.) Temperature readings shall be obtained in close proximity to the application site.
AGR FORM