Example FS-2100-02

Example
Pesticide-Use Proposal
FS-2100-0002 (REV.02/2019)
OMB 0596-0241 Exp. 2/28/2022

(Reference FSM 2150)

To complete this form, see instructions for Form FS-2100-0002, Pesticide-Use Proposal

Contact Name, Phone Number and e-mail*

Agency / Cooperator*

USDA Forest Service

Smokey Bear, (555) 555-5555, sbear@fs.fed.us

Region*

Forest/District*

R7

Date Submitted*

Canoe NF/ Big Lake RD

2/14/19

How would you like to be informed of the decision on your proposal?*

Telephone

E-mail

Both

1) OBJECTIVE
a) Project name and/or identifier
b) Specific target pests(s)
c) Purpose

a) Smokey Campground Bark Beetle Prevention

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

a) Sevin XLR Plus

b) Mountain Pine Beetle (Dendroctonus ponderosae)
c) Prevention of successful beetle attack

b) Liquid
c) No
d) 264-333
e) Carbaryl
f) 4 lbs a.i. per gallon

3) TYPE OF APPLICATION
a) Method
b) Equipment

a) Ground-based

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)

a) spray

b) High-pressure hydraulic sprayer

b) 1 gallon per 50 square feet of bark surface
c) 3.9 gallons/100 gallons or 5 oz/1 gallon
d) Water
e) 1.8 lbs a.i. per tree
f) None

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

a) Pre-designated high value trees in campground, unless they have current evidence of bark
beetle attack
b) Montana, Missoula County
c) Campground within a ponderosa pine-dominated forest, level ground, Cold Creek (perennial)
flows along north end of campground.
d) 100 trees
e) 1
f) May 2014

6) SENSITIVE AREAS
a) Special designated area (if
applicable)
b) Areas to be avoided
c) Areas to be treated with caution
File Code: 2100

a) None
b) Cold Creek, 200 foot no-spray buffer
c) Cover with plastic all camp tables, barbeques, firepits, faucets, toilets. Remove plastic once
residues have dried. Cover blackberry shrubs near units 45 and 46 with plastic as well.

For technical questions and Section 508 accommodation, please contact fseforms@fs.fed.us

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FS-2100-0002 (REV.02/2019)
OMB 0596-0241 Exp. 2/28/2022

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

a) Certified applicators only
b) In addition to label-required PPE, applicators will also wear chemical-resistant outerwear,
chemical-resistant boots. REI is 12 hours.
c) Obtain county permit prior to application; report use to county after application.
d) Stream buffer along Cold Creek, 200 feet
e) Water sensitive spray cards will be deployed during spray application to delimit the area of drift
in stream buffer. Operations will be suspended if drift reaches spray cards and at that point an
evaluation will be made until conditions to spray are in the parameters set for this project.
f) The area will be closed to public use during the spraying operation for safety reasons, and to
provide the best access for contractors and Forest Service inspectors. The area will remain closed
to public access for 5 days following treatment for an added measure of safety. The area will be
clearly posted 48 hours before spraying. After spraying is completed, signs explaining that
insecticides have recently been applied, what the chemical is, who to contact with questions, and
when the area will be opened again will be posted.

File Code: 2100

For technical questions and Section 508 accommodation, please contact fseforms@fs.fed.us

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FS-2100-0002 (REV.06/2018)
OMB 0596-0241 Exp. 12/2018

For Official Use Only

8. REVIEWER SIGNATURE(S)
a) Pesticide Use Coordinator

Date

b) Other reviewer(s)
(as necessary)

Date

Other reviewer(s)
(as necessary)

Date

Other reviewer(s)
(as necessary)

Date

c) Approval
(signature of approving official)

Date

Attach File(s)

Submit by Email
Burden Statement
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control
number. The Valid OMB control number for this information collection is 0596-0241. The time required to complete this information collection is estimated to average 2 hours per response including the
time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, gender, religion, age, disability, political beliefs, sexual
orientation, and marital or family status. (not all prohibited bases apply to all programs) Persons with disabilities who require alternative means for communication of program information (Braille, large
print, audiotape, etc) should contact USDA's TARGET Center at (202) 720-2600 (Voice and TDD).
To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, DC 20250-9410 or call (800) 795-3272 (voice) or (202) 720-6382 (TDD).
USDA is an equal opportunity provider and employer.

File Code: 2100

For technical questions and Section 508 accommodation, please contact fseforms@fs.fed.us

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