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:

Pesticides were applied by: Certified Applicator Uncert. Applicator Handler Commercial Applicator

Page 1 of 4

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

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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

Remarks:

Interviewee's Signature:

Inspector's Signature:

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

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

WITHIN STANDARDS?

Yes No C/A N/A

operating condition 170.507(b)

Worker Interview Conducted? Handler Interview Conducted?

170.507(c-d)PPE is used according to manufacturer's instructions

Pesticide free area available for storage and to change

Contaminated PPE disposed of properly 170.507(d)(2)

170.507(d)(5)

170.507(c)(2)

170.507(e)

170.507(b)(10)(iii)

170.507(b)(10)

170.507(b)(10)(i)Fit test conducted for each type of respirator required per label

Respirator training conducted 170.507(b)(10)(ii)

170.507(d)(6-7)

170.605

Decontamination Heat Duration Information Age

Page 4 of 4

Inspection Status Re-Insp F-UN C-Act No-Dis

NONC Investigation Target

Announced Unannounced Tier I1 Tier II