OCCUPANTS FUMIGATION NOTICE ANO PESTiCICIE DISCLOSURT

JOB ADDRESS

CITY

] Singte Family Dv'etling Swnerf.&g8nt:** "

T*t. !**;
Sccu

] Multi Family

Dwelling

] Other

(
{

Emergency No. (

fel. !lr.

No. { ) No. { 56f ) 866-7535 A-tr Fumigation Fumigation C0iltractor Target Fest(slr I X ] Drywood Ternrites [ ]Beetles [ ]0ther{s) Fumigants propos*d to be used: I I l{ethyl Bromide lXl Sulfuryl Fluorlde: _*YIKANE
) Prirne Csntractor

Emergrncy No.

)_-

Fmergency Emergency

{Frfiduct f,lafie)

l0the(s)

Are you aware

ofany conduitsr pipes, cornmon drains, air ducts, central vacilum sygterns sr any other construction elenrents that wnuld allow the pEssage of a fumigant from the structure to be iumigated ts any other adjacent or adjoining structurc?

YES(

) NO( )__,

"

CI.iLOROPICRIN WILL BE USED AS WARNIFIG AGTNT WITH EITHTR FUIqIANT

llat** cf filrni$stisrx

bate changes/Alterndtive d8te: Initials IMPORTANT

RTAD CAREFULLY

THIS BUILDING WILL BE FUMIGATED WITH LTTHALGASFSON THT DATE(S) INDICATTD ABOVE. ALL PIRsONS AND ANIf,4ALS MUST VACATE THE PREF{ISES 0N OR BEFORE ARRIVAL OF THf FUMIGATION CREW.

IIO CIRCUMSTANCES CAN ANYONI ENTHR THE BUiLDING UNTIL THE FUMIGATION COMPANY'S NSTICT IS POSTICI GI\1ING TFIF TIME AND DATE FOR SATE RE.ET{TRY.
UNOER.

"State law requires that you be given the fcliawing informatlon: CAUTION-PESTICIDSS ARE TSXIC Cl'lf MICALS. Structurai pest control cornpnnies are registered and regulated by the Structural pest Control Board, and app{y pesticides which are regi$tered and approved for use by the California Oepartment o'f Pesticide Regulati0n and the United $tates Environrnenta! Proteclion Agency. F,egistfation is granted when the State finds that based on existing scientific evidence there are nc appreciable risks if prcper use c0nditions are followed or that the risks are sutweighed by the benefits. The degree of risk depentls upon the degree nf exposure, so exposure should be minimized,"

If within 24 hours yni: experience symptoms of direiness, headache, nausear reduced awarenessr slowed movernent, garbled
speech or difficulty in breathing, leave the structure inmediately and seek medical attention by ccntacting your physician or Poison Control Center { 800-875-4766 ) and notifu your pest ccnlrol company. The warning agent, chlaropicrin, can cause sYrl]ptofis of tearing, respiratory distresi and vomiting. Entry ints the spaa during fumigatiqn can be fatal,
For further infornration. conta{t any of the following: Your pestcontrol corr"rpany ( See Above for }-tea}th Questions the Coun\ HealtFr Department ( See Eelow ) for Applicatisn Information th County Agrirultural Commissisner ( see Below ) and for ReEultory Infsfnration the Struch.lral pest Control Board, 8001737 - 61S8, 1005 Evergreen Street, Ste, 1500, Sacramefito, nA 95815.

) ;

POISON CONTRCIL
CTNTER

CONTROL BOARS
,LA .tJK
STATE WTDE

1909-387-6280

... ^ . 5S

909-387-2105

.......58

800-s76-4766 800-876-4766 800-876-4766

800-s76-4766

......S8

.RV

s00-737-818S

(This section may be nrodified to include the information of geographical area served by the license.)

hereby acknowledge receipt

necessarY prepfrration$

, procedures for leaving the structure, and the fol{owing Gas Cornpany Information * Fumigant Fact Sheet * F{ow To use NyIOFUME gaq!
for the
fumigation

of a copy of thi$ document as well as a li$t thit

includes the instructions for the

documents.

We suggest that you notify nearby neighbors of the date of the fumlgation and funrigation. Close off any open access to the sub area to prevent pets from entering,

to

keep pets away during

fFta

] SwrtwlAgrrtt$ignahtte]"
I Swupsnt{s} {x$na&re}

bata

43M-48 {Rev.

5/07) *-* i\l

Rrv 6:'2*08