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 States 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"
COUNTY HEALTH DEPARTMENT |
COUNTY AGRICULTURAL |
POISON CONTROL |
STRUCTURAL PEST |
(714) 834-7700 (213) 240-8203 (909) 387-6280 (909) 358-5172 |
(714) 447-7100 (818) 575-5465 |
(800) 582-3387 (800) 876-4766 |
(800) 737-8188 |
(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.
| Owner/Agent (signature) | Date | ||
| Occupants(s) (signature) | |||
43M-48 (New 5/96)