+--------------------------+-----------------+------------------------+
| **Pest Management Plan   |                 |                        |
| Checklist**              |                 |                        |
|                          |                 |                        |
| ***\[4-2006\]** Based on |                 |                        |
| Pest Management Standard |                 |                        |
| 595 dated 9-02*          |                 |                        |
+--------------------------+-----------------+------------------------+
| County                   | Date Plan       | For Crop Years:        |
|                          | Submitted       |                        |
+--------------------------+-----------------+------------------------+
| Producer/Owner \[Name,   | Farm \#         | Crop Acres             |
| Address, Phone\]         |                 |                        |
|                          | Tract #s        |                        |
+--------------------------+-----------------+------------------------+
| Technical Service        |                 | Conservation staff     |
| Provider \[Address,      |                 | planner \[Name, Field  |
| Phone, Email,            |                 | Office\]               |
| Organization,            |                 |                        |
| Registration Number\]    |                 |                        |
+--------------------------+-----------------+------------------------+

+---------------------------------+---+---+----------------------------+
| **PMP Components**              | * | * | **Comments**               |
|                                 | * | * |                            |
| The following components are    | Y | N |                            |
| ***[required]{.underline}** in* | * | * |                            |
| the Plan on a field by field    | * | * |                            |
| basis. The PMP will be          |   |   |                            |
| completed during the [first     |   |   |                            |
| year]{.underline} of any        |   |   |                            |
| incentive period or cost-share  |   |   |                            |
| program.                        |   |   |                            |
+---------------------------------+---+---+----------------------------+
| **General Information**         |   |   |                            |
+---------------------------------+---+---+----------------------------+
| 1)  Photos & maps indicate      |   |   |                            |
|     field boundaries and field  |   |   |                            |
|     ID numbers.                 |   |   |                            |
+---------------------------------+---+---+----------------------------+
| 2)  Soil map is included, with  |   |   |                            |
|     field boundaries shown.     |   |   |                            |
+---------------------------------+---+---+----------------------------+
| **Environmental Assessment**    |   |   |                            |
+---------------------------------+---+---+----------------------------+
| 1)  Environmentally sensitive   |   |   |                            |
|     areas are identified and    |   |   |                            |
|     have been discussed with    |   |   |                            |
|     producer.                   |   |   |                            |
+---------------------------------+---+---+----------------------------+
| 2)  Plan identifies potential   |   |   |                            |
|     for pest control products   |   |   |                            |
|     to degrade surface or       |   |   |                            |
|     ground water, and outlines  |   |   |                            |
|     steps to reduce potential.  |   |   |                            |
+---------------------------------+---+---+----------------------------+
| 3)  Win-PST, NAPRA, or other    |   |   |                            |
|     models used are described   |   |   |                            |
|     and results shown.          |   |   |                            |
+---------------------------------+---+---+----------------------------+
| 4)  Risk of exposure of         |   |   |                            |
|     non-target species, both on |   |   |                            |
|     and off-site, has been      |   |   |                            |
|     assessed and reduced .      |   |   |                            |
+---------------------------------+---+---+----------------------------+
| 5)  Appropriate Federal, State, |   |   |                            |
|     and local regulations are   |   |   |                            |
|     followed.                   |   |   |                            |
+---------------------------------+---+---+----------------------------+
| 6)  Farm workers and others     |   |   |                            |
|     using or exposed to         |   |   |                            |
|     pesticides are adequately   |   |   |                            |
|     protected.                  |   |   |                            |
+---------------------------------+---+---+----------------------------+
| **Pest Assessment & Planned     |   |   |                            |
| Treatments**                    |   |   |                            |
+---------------------------------+---+---+----------------------------+
| 1)  Pre-season IPM field        |   |   |                            |
|     history prepared.           |   |   |                            |
|     \[*optional*\]              |   |   |                            |
+---------------------------------+---+---+----------------------------+
| 2)  Previous, current and       |   |   |                            |
|     planned crops, crop         |   |   |                            |
|     rotations and tillage       |   |   |                            |
|     systems are indicated.      |   |   |                            |
+---------------------------------+---+---+----------------------------+
| 3)  Crop scouting completed, at |   |   |                            |
|     a minimum, during           |   |   |                            |
|     planting/emergence, early-, |   |   |                            |
|     mid-, and late- season      |   |   |                            |
|     development, and            |   |   |                            |
|     post-harvest evaluation.    |   |   |                            |
+---------------------------------+---+---+----------------------------+

+---------------------------------+---+---+----------------------------+
| **PMP Components**              | * | * | **Comments**               |
|                                 | * | * |                            |
|                                 | Y | N |                            |
|                                 | * | * |                            |
|                                 | * | * |                            |
+---------------------------------+---+---+----------------------------+
| 4)  Pests and beneficial        |   |   |                            |
|     organisms identified.       |   |   |                            |
+---------------------------------+---+---+----------------------------+
| 5)  Scouting records completed  |   |   |                            |
|     and included. \[*maps &*    |   |   |                            |
|     *reports*\]                 |   |   |                            |
+---------------------------------+---+---+----------------------------+
| 6)  Scouting completed by       |   |   |                            |
|     certified Pest Management   |   |   |                            |
|     Specialist.                 |   |   |                            |
+---------------------------------+---+---+----------------------------+
| 7)  Pesticide applications      |   |   |                            |
|     based on predicted or       |   |   |                            |
|     estimated loss and risk.    |   |   |                            |
|     \[*economic threshold*\]    |   |   |                            |
+---------------------------------+---+---+----------------------------+
| 8)  Planned control methods are |   |   |                            |
|     identified.                 |   |   |                            |
+---------------------------------+---+---+----------------------------+
| 9)  Pesticide labels are        |   |   |                            |
|     followed for all            |   |   |                            |
|     applications.               |   |   |                            |
+---------------------------------+---+---+----------------------------+
| **Management Assessment**       |   |   |                            |
+---------------------------------+---+---+----------------------------+
| Mitigation Techniques, such as  |   |   |                            |
| IPM and conservation practices, |   |   |                            |
| have been identified and are    |   |   |                            |
| being implemented to address    |   |   |                            |
| environmentally sensitive       |   |   |                            |
| areas. \[*refer to eFOTG        |   |   |                            |
| Sec.II, "Pest Management        |   |   |                            |
| Mitigation Effectiveness Guide  |   |   |                            |
| -- Reducing Pesticide Impacts   |   |   |                            |
| on Water Quality"*\]            |   |   |                            |
+---------------------------------+---+---+----------------------------+
| **Additional Items**            |   |   |                            |
+---------------------------------+---+---+----------------------------+
| 1)  The record keeping system   |   |   |                            |
|     uses Purdue ID-198/PPP-18   |   |   |                            |
|     or equivalent.              |   |   |                            |
+---------------------------------+---+---+----------------------------+
| 2)  Record keeping uses FSA     |   |   |                            |
|     tract and field numbers, or |   |   |                            |
|     cross-references other      |   |   |                            |
|     field identifiers as        |   |   |                            |
|     needed.                     |   |   |                            |
+---------------------------------+---+---+----------------------------+
| 3)  A Table of Contents is      |   |   |                            |
|     included in the plan and in |   |   |                            |
|     the record-keeping          |   |   |                            |
|     documents.                  |   |   |                            |
+---------------------------------+---+---+----------------------------+
| **An [updated implementation    |   |   |                            |
| schedule]{.underline} must be   |   |   |                            |
| submitted annually with this    |   |   |                            |
| signed checklist, to verify     |   |   |                            |
| that incentive or Technical     |   |   |                            |
| Service Provider payment may    |   |   |                            |
| occur. For NRCS Quality         |   |   |                            |
| Assurance purposes, the Plan    |   |   |                            |
| must be available for review at |   |   |                            |
| all times. All practices on     |   |   |                            |
| active EQIP contracts are       |   |   |                            |
| subject to annual status        |   |   |                            |
| reviews to verify contract      |   |   |                            |
| implementation.**               |   |   |                            |
+---------------------------------+---+---+----------------------------+
| **YEAR ONE:** This Plan was     |   |   |                            |
| developed by a certified pest   |   |   |                            |
| management specialist and meets |   |   |                            |
| minimum standards and           |   |   |                            |
| specifications for Standard     |   |   |                            |
| 595, Pest Management.           |   |   |                            |
|                                 |   |   |                            |
| **Certified Pest**              |   |   |                            |
|                                 |   |   |                            |
| **Management                    |   |   |                            |
| Specialist**\_\_\_\_            |   |   |                            |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |   |   |                            |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |   |   |                            |
| \_\_\_\_\_\_\_\_\_\_\_Date\_\_\ |   |   |                            |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |   |   |                            |
|                                 |   |   |                            |
| *Signature*                     |   |   |                            |
|                                 |   |   |                            |
| **Pr                            |   |   |                            |
| oducer/Operator**\_\_\_\_\_\_\_ |   |   |                            |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |   |   |                            |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |   |   |                            |
| \_\_\_\_\_\_\_\_\_\_\_Date\_\_\ |   |   |                            |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |   |   |                            |
|                                 |   |   |                            |
| *Signature*                     |   |   |                            |
+---------------------------------+---+---+----------------------------+

+----------------------------------------+---+---+-----------------------+
| **Annual Implementation Checklist**    |   |   |                       |
|                                        |   |   |                       |
| This checklist must be completed in    |   |   |                       |
| years one, two and three, following    |   |   |                       |
| the development of a Pest Management   |   |   |                       |
| Plan. **Explain any deviations from    |   |   |                       |
| the approved plan under "Comments",    |   |   |                       |
| below.**                               |   |   |                       |
+----------------------------------------+---+---+-----------------------+
| **Required Item**                      | * | * | **Comments**          |
|                                        | * | * |                       |
|                                        | Y | N |                       |
|                                        | * | * |                       |
|                                        | * | * |                       |
+----------------------------------------+---+---+-----------------------+
| 1)  If new pest control products are   |   |   |                       |
|     introduced to the operation, the   |   |   |                       |
|     potential for water quality impact |   |   |                       |
|     has been re-evaluated.             |   |   |                       |
+----------------------------------------+---+---+-----------------------+
| 2)  Appropriate federal, state, &      |   |   |                       |
|     local regulations are being        |   |   |                       |
|     followed.                          |   |   |                       |
+----------------------------------------+---+---+-----------------------+
| 3)  Farm workers and others exposed to |   |   |                       |
|     products are adequately protected. |   |   |                       |
+----------------------------------------+---+---+-----------------------+
| 4)  Crop scouting is completed each    |   |   |                       |
|     year.                              |   |   |                       |
+----------------------------------------+---+---+-----------------------+
| 5)  Scouting records include           |   |   |                       |
|     identification of harmful and      |   |   |                       |
|     beneficial organisms, maps, and    |   |   |                       |
|     field reports.                     |   |   |                       |
+----------------------------------------+---+---+-----------------------+
| 6)  Scouting records are completed by  |   |   |                       |
|     a certified Technical Service      |   |   |                       |
|     Provider.                          |   |   |                       |
+----------------------------------------+---+---+-----------------------+
| 7)  Pesticide labels are followed for  |   |   |                       |
|     all products and all applications. |   |   |                       |
+----------------------------------------+---+---+-----------------------+
| 8)  Mitigation techniques for          |   |   |                       |
|     environmentally sensitive areas    |   |   |                       |
|     are re-evaluated if new products   |   |   |                       |
|     or rates are introduced to the     |   |   |                       |
|     operation.                         |   |   |                       |
+----------------------------------------+---+---+-----------------------+
| 9)  The record-keeping system uses     |   |   |                       |
|     Purdue ID-198/PPP-18 or            |   |   |                       |
|     equivalent.                        |   |   |                       |
+----------------------------------------+---+---+-----------------------+
| 10) Record keeping cross-references    |   |   |                       |
|     FSA tract and field numbers with   |   |   |                       |
|     other location identifiers, if     |   |   |                       |
|     needed.                            |   |   |                       |
+----------------------------------------+---+---+-----------------------+
| 11) The entire Pest Management Plan is |   |   |                       |
|     being implemented as planned.      |   |   |                       |
+----------------------------------------+---+---+-----------------------+
| **An [updated implementation           |   |   |                       |
| schedule]{.underline} must be          |   |   |                       |
| submitted annually with this signed    |   |   |                       |
| checklist, to verify that incentive or |   |   |                       |
| Technical Service Provider payment may |   |   |                       |
| occur.**                               |   |   |                       |
+----------------------------------------+---+---+-----------------------+
| **YEAR ONE:** The final pesticide      |   |   |                       |
| application for the 1^st^ year was     |   |   |                       |
| applied according to this plan and     |   |   |                       |
| meets minimum standards and            |   |   |                       |
| specifications for Standard 595, Pest  |   |   |                       |
| Management.                            |   |   |                       |
|                                        |   |   |                       |
| **Certified Pest**                     |   |   |                       |
|                                        |   |   |                       |
| **Management                           |   |   |                       |
| Specialist**\_\_\_\_\_\_\_\_\_         |   |   |                       |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |   |   |                       |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Da |   |   |                       |
| te\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |   |   |                       |
|                                        |   |   |                       |
| *Signature*                            |   |   |                       |
|                                        |   |   |                       |
| **Produ                                |   |   |                       |
| cer/Operator**\_\_\_\_\_\_\_\_\_\_\_\_ |   |   |                       |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |   |   |                       |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Da |   |   |                       |
| te\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |   |   |                       |
|                                        |   |   |                       |
| *Signature*                            |   |   |                       |
+----------------------------------------+---+---+-----------------------+
| **YEAR TWO:** This Plan is being       |   |   |                       |
| implemented, and meets minimum         |   |   |                       |
| standards and specifications for       |   |   |                       |
| Standard 595, Pest Management.         |   |   |                       |
|                                        |   |   |                       |
| **Certified Pest**                     |   |   |                       |
|                                        |   |   |                       |
| **Management                           |   |   |                       |
| Specialist**\_\_\_\_\_\_\_\_\_         |   |   |                       |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |   |   |                       |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Da |   |   |                       |
| te\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |   |   |                       |
|                                        |   |   |                       |
| *Signature*                            |   |   |                       |
|                                        |   |   |                       |
| **Produ                                |   |   |                       |
| cer/Operator**\_\_\_\_\_\_\_\_\_\_\_\_ |   |   |                       |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |   |   |                       |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Da |   |   |                       |
| te\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |   |   |                       |
|                                        |   |   |                       |
| *Signature*                            |   |   |                       |
+----------------------------------------+---+---+-----------------------+
| **YEAR THREE:** This Plan is being     |   |   |                       |
| implemented, and meets minimum         |   |   |                       |
| standards and specifications for       |   |   |                       |
| Standard 595, Pest Management.         |   |   |                       |
|                                        |   |   |                       |
| **Certified Pest**                     |   |   |                       |
|                                        |   |   |                       |
| **Management                           |   |   |                       |
| Specialist**\_\_\_\_\_\_\_\_\_         |   |   |                       |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |   |   |                       |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Da |   |   |                       |
| te\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |   |   |                       |
|                                        |   |   |                       |
| *Signature*                            |   |   |                       |
|                                        |   |   |                       |
| **Produ                                |   |   |                       |
| cer/Operator**\_\_\_\_\_\_\_\_\_\_\_\_ |   |   |                       |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |   |   |                       |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Da |   |   |                       |
| te\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |   |   |                       |
|                                        |   |   |                       |
| *Signature*                            |   |   |                       |
+----------------------------------------+---+---+-----------------------+