Form FS-2100-2 Pesticide Use Proposal

Forest Service Pesticide-Use Proposal Form

0596-NEW FS-2100-2 v11-03-2015

Pesticide Use - Individuals

OMB: 0596-0241

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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:





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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