68
DAILY PESTICIDE REPORT (M&R-629)
(This ODOT required form must be completed on a daily basis when making herbicide applications.)
EXAMPLE WORKSHEET
LOCATION
WORK
KEY
1
2
3
4
COUNTY
ROUTE
MATERIAL
MASTER
CODE
&
EPA
REGISTRATION
NUMBER
ROUTE
TYPE
LANE
DIRECTION
SPOT
OR
SLM
FACILITY
OR
SLM
UNIT
OF
MEASURE
1
2
3
4
UNIT
MATERIAL
MASTER
CODE
&
EPA
REGISTRATION
NUMBER
START
TIME
STOP
TIME
DESCRIPTION
(SEE
PAGE
2)
ACTIVITY
CODES
ACCOMPLISHMENT
UNIT
MAINTENANCE
ACTIVITY
CODE
Miles
Guardrail/signpost
M691-002
Herbicidal
Spraying
10am
8am
2
1.1
-
3.1
Ascending
#57020293
Herbicide,
Roundup
Pro
-
#524-475
IR
23
PIC
MATERIALS
Gals
3
#
57020293
HERBIDICE,
ROUNDUP
PRO
-
#524-475
#
57020380
HERBICIDE,
SURFLAN
-
#1471-113
#
57020770
HERBICIDE,
TRANSLINE
-
#62719-73
#
57020220
HERBICIDE,
KRENITE
-
#352-439
#
57020500
HERBICIDE,
ESCORT
-
#352-439
#
57020540
HERBICIDE,
PATH-
WAY
-
#62719-31
#
57020280
HERBICIDE,
RODEO
-
#524-343
#
57020735
TORDON
101
-
#62719-5
#
57020260
HERBICIDE,
OUST
-
#352-401
#
57020092
HERBICIDE,
PATHFINDER
II
-
#62719-176
GAL GAL GAL GAL GAL GAL GAL GAL
OZ OZ
EQUIPMENT
LABOR
NO.
NO.
EQUIPMENT
NUMBER
EMPLOYEE
NAME
APPLICATOR
LIC.
#
TOTAL
R
R
R
R
O
O
O
O
LIC#
BEGIN
END
MILES
Hrs
1 1
2 2
3 3
4 4
HRs
on
JOB
1
1 2
2220607
John
Doe
26939
none
3.5 3.5
3.5 3.5
Jane
Doe
T6786
3
20450
20480
30
SHEET
___
OF
___
DATE:
_____________
M&R-629,
REVISED
02/17
Page
1
of
2
