Pesticide Use Burden - State, Local & Tribal

USDA Forest Service FS-2100-2 instructions (v12-2015)

OMB 0596-NEW exp. XX/201X

Instructions for Form FS-2100-2, Pesticide-Use Proposal

AGENCY INFORMATION (Header)

Provide requested information.

How would you like to be informed of the decision on your proposal? Please check one option.

OBJECTIVE (Block 1)

a) Project name and/or identifier – Include the local project name and/or identifying name such as the name of the relevant NEPA compliance document and date of decision. [Note–Environmental analyses (EA's and/or EIS's) may be cited within the Pesticide-Use Proposal for additional information.]

b) Specific target pest(s) – Identify target pest(s) by the common and scientific name. Also identify the life cycle stage for animals (adult, larva, etc.) or stage of growth for plants (pre-emergent, seedling, sapling, etc.) at the time of application. A table may be attached to list information for multiple targets.

c) Purpose – State exact purpose of pesticide use.

PESTICIDE PRODUCT(S) (Block 2)

a) Trade name – State the trade name(s) exactly as shown on container (e.g., Roundup Ultra, Tordon 22k, Sevin SL).

b) Formulation as purchased – State the formulation (liquid, dust, granule, pellet, emulsion, bait, solution (ready-to-use without dilution), gas, flakes, packets, etc.) of each pesticide product as purchased.

c) Restricted-use pesticide (yes/no) – Specify whether the pesticide is a restricted-use pesticide or not.

d) EPA registration number – State the EPA registration number from the pesticide label.

e) Common name of chemical(s) – State the common name (glyphosate, picloram, carbaryl, etc.) of active ingredient(s) as given on the pesticide label. When more than one pesticide active ingredient will be used during treatment of a single pest, list active ingredients separately by placing the word "and" between them to indicate the different pesticide names (e.g., aminopyralid and 2, 4-D). When alternative materials are proposed for the application, use the word "or" in listing the names.

f) AI, AE, IU, or PIB expressed as % or concentration – State the percentage (%) or concentration (lb/gal, oz/oz, etc.) of any active ingredient (AI), acid equivalent (AE), international units (IU), or polyhedral inclusion bodies (PIB) as shown on the pesticide label. For herbicides, report as acid equivalent rather than active ingredient when available. IU may be expressed as billion international units/gal for bacteria, and PIB may be expressed as billion polyhedral inclusion bodies/oz for viruses, as appropriate.

TYPE OF APPLICATION (Block 3)

a) Method – Indicate the specific method of application to be used (aerial, ground, aquatic, etc.).

b) Equipment – Indicate the specific type of equipment to be used such as backpack sprayer, helicopter, fixed-wing aircraft, mist blower, hydraulic sprayer, injector, packets, etc.

FIELD APPLICATION INFORMATION (Block 4)

a) Formulation of material to be applied – Indicate the pesticide material to be applied in the field (spray liquid, pellets, granules, dust, bait, gas, flakes, packets, etc.).

b) Planned application rate – Indicate the amount of liquid or dry material to be applied on a per unit area basis (gal/acre, lbs/acre, oz/1,000 ft², etc.). In general, calibration of liquid sprayers requires determination of the application rate in gallons per acre (GPA).

c) Dilution rate – Indicate the pesticide concentration to be applied in the field as the amount of concentrate to be mixed with a specified amount of diluent (e.g., 1 qt. Tordon 22K/25 gallons of total mix).

d) Diluent – Identify the material (water, oil, talc, etc.) that will be used to reduce the concentration of a pesticide formulation at the time of application.

e) Pounds of AI or AE per acre (or other applicable rate) – State the pounds of active ingredient (AI) or acid equivalent (AE) (specify which) to be applied on a per acre basis, unless some other unit is indicated on the label. If reporting acreage is not appropriate, indicate units used. If a pesticide for trees or brush is to be applied by aircraft or mist blower, express as pounds of AI or AE per acre. For outdoor spot applications, the rate of application should also be expressed in pounds of AI or AE per acre. For pesticide treatment of individual trees, the application rate for AI or AE is described as number of trees and rate per tree (or an equivalent measure).

Indoor applications of residual sprays may be expressed as gallons per 1,000 square feet (at whatever percent AI in the prepared spray) or simply as pounds AI per 1,000 square feet. For spraying pesticide on most indoor surfaces to the point of runoff, assume the rate to be 1 gallon of formulation per 1,000 square feet. If a dust is being used, express as ounces or pounds of AI in prepared dust per M (1,000) square feet. The AI rate of application for fumigants or indoor aerosols is expressed as pounds AI per M (1,000) cubic feet. Rodent baits should be given as ounces or pounds of AI in the prepared bait per bait station.

The rate of application of AI for pesticide treatments in water may be expressed in parts per million (ppm) or parts per billion (ppb). Specify whether ppm or ppb is by weight or volume.

f) Other pesticides being applied to proposed treatment site(s) – Indicate other pesticides currently being applied or will be applied to the same site(s) proposed for treatment within the same year (e.g., ongoing carbaryl treatment of trees in the same campground where invasive plants will be treated; pesticides applied under other Pesticide-Use Proposals within the same treatment area).

TREATMENT AREA DESCRIPTION (Block 5)

a) Targeted treatment area – Specify area(s) to be treated (wilderness area, stretch of river, grazing allotment, etc.).

b) State and county – Indicate State(s), county(ies), and any other geographic jurisdictions involved with the area(s) to be treated.

c) Site description – Provide information on the type of area (rangeland, tree nursery, etc.) to be treated and any specific parts or portions of the area that will be treated such as ditch banks, rights-of-way, etc. When applicable, specify whether the pesticide will be applied directly to water or near the water’s edge (e.g., riparian area). State the distance to nearest surface water (lakes, streams, etc.) or wetland. Where applicable, indicate the general slope of the treated area(s). For aquatic applications, indicate water quality (hardness and pH) of treated water body if available or applicable.

d) Estimate of acres (or other unit) to be treated – Provide an estimate for acres to be treated, unless other units are otherwise applicable. When projects require repeat applications, estimate only those acres to be treated in the first application.

e) Number of applications – For projects that will require repeat applications within the same area, provide an estimate of the number of treatments that will be used per season.

f) Month(s) and year(s) of application – Indicate the month(s) and year(s) that applications are planned. If necessary, provide general season of treatment (e.g., spring, summer, or fall) or an estimate of the range of years for treatment (e.g., 2011 through 2019).

SENSITIVE AREAS (Block 6)

a) Special designated area (if applicable) – Identify any wilderness area, Research Natural Area (RNA), botanical area, or other similar designated area that is in proximity to areas to be treated. Describe specific precautionary measures that will be taken to protect identified special designated area (e.g., no pesticide application with mechanical ground equipment inside wilderness area).

b) Areas to be avoided – Identify specific areas to be protected from direct application, drift, or runoff (waterbodies, private property, T&E species habitat, etc.). Describe specific precautionary measures that will be taken to avoid presence of pesticide in identified area (e.g., no application within 100 feet of stream).

c) Areas to be treated with caution – Identify sensitive areas (riparian areas, areas with a shallow water table, T&E species habitat, etc.) that require special precautions during treatment to avoid undue impacts or contamination. Describe specific precautionary measures that will be taken to protect identified area (e.g., use of pesticides with an aquatic label in riparian areas).

PROJECT IMPLEMENTATION (Block 7)

a) Trained/certified personnel to be used – Provide information regarding personnel who will be performing the actual pesticide work. Applicators and personnel serving as supervisors must be trained in the proper application of pesticides. Personnel handling or applying a restricted-use pesticide must be state or Federally certified for restricted-use pesticide operations.

b) Personal safety – State any restricted entry interval (REI) required by the pesticide label following application. If additional personal protection equipment other than what is on the label is proposed, please describe.

c) State and local coordination – Indicate any coordination at the State or local level that will be made for the project.

d) Best management practices – Describe or reference the best management practices that will be followed for pesticide application such as lowest effective application rate, equipment calibration, field scouting/monitoring before pesticide application, buffer zones, and weather restrictions (wind speed limit, inversion avoidance, etc.).

e) Monitoring – Describe monitoring required for treatment effectiveness and any other monitoring that will be conducted.

f) Additional project information – Describe other information pertinent to the project that is not addressed in sections above (e.g., information as to whether the project will be conducted by force account or through a contract).

SUBMISSION

Please contact the U.S. Forest Service Region/Area Pesticide Use Coordinator in advance to inform him/her of the method in which the form will be submitted (in person or by courier, via e-mail, or via U.S. Postal Service).

The following website has the List of Pesticide Use Coordinators by Region/Area:

http://www.fs.fed.us/foresthealth/pesticide/contactus.shtml

REVIEWER(S) (Block 8)

a) Pesticide use coordinator – A pesticide use coordinator’s signature at the district, forest, or regional level (as appropriate) is required before final approval.

b) Other reviewers (as necessary) – Include any necessary signature(s) of specialists in pertinent programs such as biologists, entomologists, agronomists, wilderness program managers, or Research Natural Area (RNA) program managers that are required before final approval.

APPROVAL (signature of approving official) (Block 9)

Signature of approving line officer with delegated signing authority

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-NEW. 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.

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