Structural Pest Control & Pesticides Division PESTICIDE SECTION 1090 Mail Service Center, Raleigh, NC 27699 (919) 733-3556 NORTH CAROLINA DEPARTMENT of AGRICULTURE & CONSUMER SERVICES Date Insp. Type Sequence Reason Facility Func. Use Site WPS INSPECTION County Code Facility Name Address City Lic. Code License Number Phone Number Licensee State Zip Code NCDA&CS SPC&PD (REV 01/19 RTS) ESTABLISHMENT TYPE Farm Forest Nursery Enclosed Space Crops Grown: Blueberries Corn Cotton Forestry Fruits, other GH/Nursery Hay Pasture Peanuts Small Grains Soybeans Strawberries Sugar Beets Tobacco Vegetables Christmas Trees Other N/A Site Information Total Size in acres: Enclosed Space square feet: Number of handlers: Number of workers: Permanent Seasonal Number of certified applicators: Season of year with highest number of workers: Does this establishment meet the immediate family exemption for WPS? Number of handlers: A. Agriculture Establishment B. Commercial Pesticide Handling Establishment VT Are all non-exempt Handlers & Early-Entry Workers at least 18 years of age? Does this establishment use Labor Contractors to provide labor? Commercial Applicator Aerial Applicator Yes No Yes No Yes No Pesticides applied bearing WPS on the label 1. Brand Name: EPA Reg No: Date of Application REI: PPE: Yes No Respirator Required? Yes No Type of Respirator Used: 2. Brand Name: EPA Reg No: Date of Application REI: PPE: Yes No Respirator Required? Yes No Type of Respirator Used: 3. Brand Name: EPA Reg No: Date of Application REI: PPE: Yes No Respirator Required? Yes No Type of Respirator Used: Pesticides were applied by: Certified Applicator Uncert. Applicator Handler Commercial Applicator Page 1 of 4
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Structural Pest Control & Pesticides Division PESTICIDE SECTION
1090 Mail Service Center, Raleigh, NC 27699 (919) 733-3556
NORTH CAROLINA DEPARTMENT of AGRICULTURE & CONSUMER SERVICES
Date
Insp. Type
Sequence
Reason Facility Func. Use Site
WPS INSPECTION County Code Facility Name
Address
City
Lic. Code License Number
Phone Number
Licensee
State Zip Code
NCDA&CS SPC&PD (REV 01/19 RTS)
ESTABLISHMENT TYPEFarm Forest Nursery Enclosed Space
Crops Grown:BlueberriesCornCotton
ForestryFruits, otherGH/Nursery
HayPasturePeanuts
Small GrainsSoybeansStrawberries
Sugar BeetsTobaccoVegetables
Christmas TreesOtherN/A
Site InformationTotal Size in acres: Enclosed Space square feet:
Number of handlers:
Number of workers: Permanent Seasonal
Number of certified applicators:
Season of year with highest number of workers:
Does this establishment meet the immediate family exemption for WPS?
Number of handlers:
A. Agriculture Establishment
B. Commercial Pesticide Handling Establishment
VT
Are all non-exempt Handlers & Early-Entry Workers at least 18 years of age?Does this establishment use Labor Contractors to provide labor?
Commercial Applicator Aerial Applicator
Yes NoYes No
Yes No
Pesticides applied bearing WPS on the label
1. Brand Name:
EPA Reg No:Date of Application REI:
PPE: Yes NoRespirator Required? Yes No Type of Respirator Used:
2. Brand Name:
EPA Reg No:Date of Application REI:
PPE: Yes NoRespirator Required? Yes No Type of Respirator Used:
3. Brand Name:
EPA Reg No:Date of Application REI:
PPE: Yes NoRespirator Required? Yes No Type of Respirator Used:
Employer information exchange conducted accordingly
Workers and non-certified handlers trained within the past 12 months
3.
Pesticide Application Details & SDS kept for 2 years
EMPLOYER DUTIES FOR WORKERS & HANDLERS
Information Display & Communication WITHIN STANDARDS?1.
If No, List items missing
Safety Data Sheets (SDS)
170.311(b) & 02 NCAC 09L.1807
Required information displayed before worker entry or within 24 hours of application and for at least 30 days after REI has expired
2.
3.
4.
5.
6.
7.
8.
11.
10.
Safety Training1.
Safety training records complete
Safety training records kept for 2 years
Trainer was qualified to train worker/handlers
EPA approved training material used (list below)2.
4.
5.
If No, List items missing
Other Duties WITHIN STANDARDS?1. Emergency assistance provided to workers/handlers
3.
9.
2. Pesticide product information provided to medical personnel
EPA approval number/code
Date Time Crop or Site Treated Location REI
Where is the information displayed?Break Room Shed Office Service Truck Porta John
N/ADecon Site Other
Yes No C/A N/A
Yes No C/A N/A
Yes No C/A N/A
Yes No C/A N/A
Yes No C/A N/A
Yes No C/A N/A
WITHIN STANDARDS?Yes No C/A N/A
Yes No C/A N/A
Yes No C/A N/A
Yes No C/A N/A
170.311(a)(3)(x)
Safety Poster 170.311(a)
Medical Facility Information 170.311(a)(3)(ix)
NCDA&CS' Pesticides Section Information
Pesticide Application Details 170.311(b)(1)
Product Info
170.311(b)(1)(i)
Yes No C/A N/A 170.309(h) & 170.311(b)(5)
Information is legible and located in an accessible area during work hours where workers & handlers congregate or pass by 170.311(b)(2-4)
Is safety information displayed at all permanent decon sites andsites for 11 or more workers 170.311(a)(5)(ii)
Pesticide Application Details and SDS made available upon requestto a worker, handler, treating medical personnel, or designatedauthorized representative 170.311(b)(7-9)
170.401(a) & 170.501(a)
170.401(c) & 170.501(c)
170.401(c)(4) & 170.501(c)(4)
170.401(d) & 170.501(d)
170.401(d) & 170.501(d)
170.309(f)
170.309(f)(2)
170.313(i) & 170.309(k)
Yes No C/A N/A
Video Booklet Flip Chart PowerPoint Other
Certified Applicator Designated Trainer
Name Signature Date Material Used Trainer's Name Qualifications Employer
Yes No C/A N/A
Yes No C/A N/A
Yes No C/A N/A
Yes No C/A N/A
Yes No C/A N/A
Yes No C/A N/A
Page 2 of 4
Workers are notified of applications
EMPLOYER DUTIES FOR WORKERS & HANDLERS
Decontamination (Worker)1. Decontamination supplies located within 1/4 mile
1 gallon of water provided for each worker
Other supplies provided as required
2.
3.
4.
5.
Posting & Notification WITHIN STANDARDS?1.
Warning signs used if required (by label, over 48 hour REI for outdoor, or over 4 hour REI for enclosed space production)
2.
If No, List items missing
Decontamination (Handler) WITHIN STANDARDS?
1. Decontamination supplies located within 1/4 mile and at permanentmix/load sites
3 gallons of water provided for each handler
Decontamination supplies protected from pesticide application
Other supplies provided as required
2.
3.
4.
5.If No, List items missing
Are the appropriate warning signs used accordingly (language, size, verbiage, placement, etc)
3.
4.
Enclosed space production restrictions observed
Sight/voice contact at 2-hour intervals (Skull & Crossbone)
2.
1.
3.
Application Restrictions
If no, list restrictions not followed
5.
Yes No C/A N/A
WITHIN STANDARDS?Yes No C/A N/A
Yes No C/A N/A
Yes No C/A N/A
Yes No C/A N/A
Yes No C/A N/A
Yes No C/A N/A
Yes No C/A N/A
Yes No C/A N/A
Yes No C/A N/A
Yes No C/A N/A
Yes No C/A N/A
Yes No C/A N/A
Yes No C/A N/A
Fumigant Ventilation Entry Restrictions Other
Yes No C/A N/A
Yes No C/A N/A
Yes No C/A N/A
170.411(c)
Decontamination supplies located outside of treated area under an REI and reasonably accessible 170.411(d)
170.411(b)
Water is of a quality and temperature that will not cause illness or injury 170.411(b)(1)
170.509(c) & 170.509(c)(1)
170.509(c)(3)
170.509(b)
Water is of a quality and temperature that will not cause illness or injury 170.509(b)(1)
170.509(b)(2-3) & 170.509(a&d)
170.409(a)
170.409(a)(1)(ii & iv)
170.409(b)(1-3)
Pesticide applications made so as to assure no contact (directly or through drift) to workers or persons other than an appropriately equipped handler 170.505(a)
170.405(b) & 170.505(d)
170.505(c)
Workers kept out of treated area during REI (unless underearly entry) 170.309(l)
Were workers and other persons kept out of the applicationexclusion zone on the establishment 170.405(a)
Soap Towels
170.411(b)(2)
Eye Wash (if applicable)
WITHIN STANDARDS?Yes No C/A N/A
Soap Towels Change of Clothing Eye Wash (if applicable)
Oral Posted Signs
Page 3 of 4
EMPLOYER DUTIES FOR HANDLERS & EARLY ENTRY
PPE1. PPE required by label is provided, clean, and in proper
PPE is properly inspected before each day of use
Measures taken to prevent heat related illness
2.
3.
4.
5.
6.
Respiratory Protection1. Handler received medical clearance
Respirator safety records kept for 2 years
Respirator used, maintained, and replaced according to manufacturer'srecommendations, pesticide product labeling, and WPS requirements
2.
3.
4.
5.
Early Entry1. Were all Early-Entry Requirements followed
If no, list requirements not followedException Training PPE