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Agriculture Form

Free Fillable Pesticide Application Record

Fill out this pesticide application record online and download as PDF - free, no signup required.

AG-0751 fieldscompliance

Project Information

Project Information

Project Name / Operation Name*

Grower / Owner Name*

Field ID / Name*

Field Size (Acres)

Application Date*

Application Start Time

Application End Time

Crop / Site Treated*

Crop Growth Stage at Application

Product & EPA Registration Number

Product & EPA Registration Number

Product Name (Trade Name)*

Active Ingredient(s)

EPA Registration Number*

Pesticide Type*

Formulation

Application Rate & Method

Application Rate & Method

Application Rate (per acre)*

Rate Unit*

Total Area Treated (acres)*

Total Product Used

Total Product Unit

Water Carrier Volume (gal/acre)

Application Equipment*

Equipment ID / License Plate

Nozzle Type / Size

Boom Pressure (psi)

Ground Speed (mph)

Boom Height (inches)

REI & PHI Tracking

REI & PHI Tracking

Restricted Entry Interval (REI, hours)

REI Expiration Date & Time

Pre-Harvest Interval (PHI, days)

Earliest Allowable Harvest Date

Field Posting RequiredField Posting Required

Sensitive Area / Buffer Zone AppliedSensitive Area / Buffer Zone Applied

Applicator Certification

Applicator Certification

Applicator Name*

Applicator License / Certification Number*

License Category

License Expiration Date

Supervising Licensed Applicator (if applicable)

PPE Used

Chemical-Resistant GlovesProtective Eyewear / Face ShieldChemical-Resistant ApronRespiratorCoverallsChemical-Resistant Footwear

Weather Conditions at Application

Weather Conditions at Application

Temperature (°F)

Wind Speed (mph)

Wind Direction

Relative Humidity (%)

Sky Conditions

Temperature Inversion Conditions CheckedTemperature Inversion Conditions Checked

Application Notes

Application Notes

Tank Mix Partners

Adjuvants / Surfactants Used

Off-Target Drift ObservedOff-Target Drift Observed

Additional Notes

Photos

Photos

Location

Location

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