Western Regions Pesticide Meeting May 2010 Inspection Checklist

SOIL FUMIGANT USE INSPECTION (for Applications in 2010) FIRM/FARM INSPECTED Name:Firm/F arm Phone: Cell: Office: Interviewee Phone: Cell: Other Phone: Firm/Farm Physical Address-City/Zip Code: Mailing Address-City/Zip Code: Person Interviewed:Title: APPLICATOR INFORMATION Name of Applicator Supervising the Fumigation:Licen se/Ce rtificat ion Numb er: Exp Date: Certification Type: □ Private □ Commercial Employer Name: Employer Address-City/Zip Code:Phone:

3 APPLICATION INFORMATION Name of owner/operator of Application Block/Site:Phone: Physical Address/ Zip Code of Application Block/Site: Global Positioning System (GPS) Coordinates:Target Application Date/Window: EPA Registration Number:Bra nd Na me of Fu mig ant: Crop /Area Treated: Batch/Lot #: Tar get Pe st: Size in Acres: Dilution Rate: The following information is required for the Fumigation Management Plan (FMP) TARPS (check here if section is not applicable  ) Brand Name: □ Tarp Lot #: □ Thickness: □

4 SOIL CONDITIONS Description of soil texture: □ Description of moisture in application block: □ Description of method used to determine soil moisture level: □ Description of crop residue: □ Soil temperature at beginning of application is recorded: □ WEATHER CONDITIONS Summary: Weather Forecast for Day of the Application: □ Summary: Weather Forecast for 48-hour period following the application: □ Predicted Wind Speed: □ Inversion Conditions: □ Air-stagnation Advisories: □ Copy of printed forecast attached to FMP: □ DOCUMENTATION:PERSONAL PROTECTIVE EQUIPMENT-HANDLERS Handler Task: □ Respirator Change-out Schedule: □ Clothing: □ Eye Protection: □ Respirator Type: □ Gloves: □ Filter Cartridge Type: □ Other: □

5 DOCUMENTATION: EMERGENCY RESPONSE PLAN Description of Evacuation Routes: □ Local/state/federal contacts: □ Locations of Telephones: □ Other Contact Information for Emergencies: □ Contact Information for First Responders: □ Emergency procedures/responsibilities in case of an incident, equipment/tarp/seal failure, complaints, or other emergencies): □ DOCUMENTATION: POSTING SIGNS-FUMIGANT TREATMENT AREA Name of Person that Did the Posting: □ Location of Posting Signs: □

6 DOCUMENTATION: COMMUNICATION BETWEEN APPLICATOR, LAND OWNER/OPERATOR, & OTHER ON-SITE HANDLERS Plan for communicating to the land owner/operator and all on-site handlers (e.g., tarp perforators/removers, irrigators) requirements to comply with label including timing of tarp perforation/removal and PPE: □ List of Names & Phone Numbers of Persons Contacted: □ Dates When Persons Were Contacted: □ Any Additional Comments/Notes: □ HANDLER INFORMATION DOCUMENTATION: FUMIGANT HANDLER INFORMATION Handler Name: □ Handler Address: □ Handler Phone: □ Handler Tasks Trained On: □ Handler Tasks Authorized to Perform: □ Date of Medical Qualification to Wear Respirator: □ Date of Respirator Fit Testing: □ Date of PPE Training: □ DOCUMENTATION: FUMIGANT HANDLER EMPLOYER INFORMATION: Employer Name: □ Employer Address: □ Employer Phone Number: □ AIR MONITORING PLAN DOCUMENTATION: Sensory Irritation Experienced: □ Operations Ceased: □ Operations Continued: □ If operations were ceased—is there documentation of: handler name, address & phone # of personnel who performed monitoring activities before operations resumed: □ Monitoring Equipment Documented: □