Form FS-2100-2 Pesticide Use Proposal

USDA Forest Service FS-2100-2 (v05-2014)

OMB 0596-NEW Exp. XX/201X

PESTICIDE-USE PROPOSAL (Reference FSM 2150) To complete this form, see Instructions for Form FS-2100-2, Pesticide-Use Proposal
AGENCY/ COOPERATOR	CONTACT NAME, PHONE NUMBER, and E-MAIL	REGION	FOREST/ DISTRICT	DATE SUBMITTED
How would you like to be informed of the decision on your proposal?		Please choose one: ___ Telephone ___ Email ___ Both
1) OBJECTIVE a) Project name and/or identifier b) Specific target pest(s) c) Purpose
2) PESTICIDE PRODUCT(S) a) Trade name b) Formulation as purchased c) Restricted-use pesticide (yes/no) d) EPA registration number e) Common name of chemical(s) f) AI, AE, IU, or PIB expressed as % or concentration
3) TYPE OF APPLICATION a) Method b) Equipment
4) FIELD APPLICATION INFORMATION a) Formulation of material to be applied b) Planned application rate c) Dilution rate d) Diluent e) Pounds of AI or AE per acre (or other applicable rate) f) Other pesticides being applied to proposed treatment site(s)
5) TREATMENT AREA DESCRIPTION a) Targeted treatment area b) State and county c) Site description d) Estimate of acres (or other unit) to be treated e) Number of applications f) Month(s) and year(s) of application
6) SENSITIVE AREAS a) Special designated area (if applicable) b) Areas to be avoided c) Areas to be treated with caution
7) PROJECT IMPLEMENTATION a) Trained/certified personnel to be used b) Personal safety c) State and local coordination d) Best management practices e) Monitoring f) Additional project information
For Official Use Only
8) REVIEWER(S) SIGNATURE(S) a) Pesticide use coordinator Date: b) Other reviewer(s) (as necessary) Date:
9) APPROVAL (signature of approving official) Date:

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