SAMPLE OCCUPANTS FUMIGATION NOTICE AND PESTICIDE DISCLOSURE

JOB ADDRESS______________________________ CITY_________________________
[] Single Family Dwelling [] Multi Family Dwelling [] Other ____________________________ Owner/Agent_______________________________________________________________
Tel. No. (     ) ________________________ Emergency No. (     ) _____________________ Occupant__________________________________________________________________
Tel. No. (     ) _________________________Emergency No. (    ) _____________________
Prime Contractor___________________________ Emergency No. (     ) ________________
Fumigation Contractor _______________________Emergency No. (     ) ________________
Target Pest(s): [] Drywood Termites[] Beetles[] Other(s) ______________________________
Fumigant proposed to be used: [] Methyl Bromide[] Vikane(Active Ingredient - Sulfuryl Fluoride)
[] Other(s) ________________________________________________________________

CHLOROPICRIN WILL BE USED AS WARNING AGENT WITH EITHER FUMIGANT

 Dates of fumigation:_________________ Date changes/Alternative date: _________________
                                                                  Initials __________

 IMPORTANT - READ CAREFULLY

THIS BUILDING WILL BE FUMIGATED WITH LETHAL GASES ON THE DATE (S) INDICATED ABOVE. ALL PERSONS AND ANIMALS MUST VACATE THE PREMISES ON OR BEFORE ARRIVAL OF THE FUMIGATION CREW.

UNDER NO CIRCUMSTANCES CAN ANYONE ENTER THE BUILDING UNTIL THE FUMIGATION COMPANY'S NOTICE IS POSTED GIVING THE TIME AND DATE FOR SAFE RE-ENTRY.

"State law requires that you be given the following information: CAUTION-PESTICIDES ARE TOXIC CHEMICALS. Structural pest control companies are registered and regulated by the Structural Pest Control Board, and apply pesticides which are registered and approved for use by the California Department of Pesticide Regulation and the United State Environmental Protection Agency. Registration is granted when the State finds that based on existing scientific evidence there are no appreciable risks if proper use conditions are followed or that the risks are outweighed by the benefits. The degree of risk depends upon the degree of exposure, so exposure should be minimized."

If within 24 hours you experience symptoms of dizziness, headache, nausea, reduced awareness, slowed movement, garbled speech or difficulty in breathing, leave the structure immediately and seek medical attention by contacting your physician or Poison Control Center (telephone number) and notify your pest control company. The warning agent, chloropicrin, can cause symptoms of tearing, respiratory distress and vomiting. Entry into the space during fumigation can be fatal.

For further information, contact any of the following: Your pest control company (telephone number); for Health Questions - the County Health Department (telephone number); for Application Information - the County Agricultural Commissioner (telephone number) and for Regulatory Information - the Structural Pest Control Board, 800/737-8188, 1418 Howe Avenue, Sacramento, CA 95825.

FOR HEALTH QUESTIONS:

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

I hereby acknowledge receipt of a copy of this document as well as a list that includes the instructions for the necessary preparations for the fumigation, procedures for leaving the structure, and the following documents.
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
We suggest that you notify nearby neighbors of the date of fumigation and to keep pets away during the fumigation. Close off any access to the subarea to prevent pets from entering.

[ ]Owner/Agent (signature)______________________________ Date __________________
[ ]Occupant (s) (signature)_____________________________________________________
_________________________________________________________________________
_________________________________________________________________________

 43M-48 (Rev. 5/07)