OCCUPANTS FUMIGATION NOTICE AND PESTICIDE DISCLOSURE
[ ] Single Family Dwelling [ ] Multi Family Dwelling [ ] Other ___________________
Tel. No. ( ) _____________________________ Emergency No. ( ) _____________________
Tel. No. ( ) _____________________________ Emergency No. ( ) ______________________________
Prime Contractor ____________________________ Emergency No. ( ) ___________________________
Fumigation Contractor: BENEFICIAL EXTERMINATING (310) 675-6200 Emergency No. (562) 598-6270
Target Pest(s): Drywood Termites Beetles Bed Bugs Other:__________________________
Fumigants proposed to be used: Sulfuryl Fluoride Master Fume Sulfuryl Fluoride Vikane
Are you aware of any conduits, pipes, common drains, air ducts, central vacuum systems or any other construction elements that would allow the passage of a fumigant from the structure to be fumigated to any other adjacent or adjoining structures? YES ( ) NO ( ) Int. __________ If Yes, Please Describe:
CHLOROPICRIN WILL BE USED AS WARNING AGENT WITH EITHER FUMIGANT
Dates of fumigation _______________________ Date changes/ Alternative date: _________________
_______________________________________ Initials __________
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 (see below) 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 (562) 598-6270; for Health Questions – the County Health Department (see below); for Application Information – the County Agricultural Commissioner (see below) and for Regulatory Information – the Structural Pest Control Board, 800/737-8188, 2005 Evergreen Street, Ste. #1500, Sacramento, CA 95815.
FOR HEALTH QUESTIONS:
|COUNTY HEALTH DEPARTMENT||COUNTY AGRICULTURAL COMMISSIONER||POISON CONTROL CENTER||STRUCTURAL. PEST CONTROL BOARD|
|Los Angeles (800) 427-8700||Los Angeles (626) 575-5466||(800) 411-8080||(800) 737-8188|
|Orange (714) 834-8180||Orange (714) 955-0100||(800) 876-4766|
|Riverside (951) 358-5172||Riverside (951) 955-3045|
|San Bernardino (800) 442-2283||San Bernardino (909) 387-2105|
|San Diego (619) 692-8499||San Diego (858) 694-8980|
|Santa Barbara (805) 681-4900||Santa Barbara (805) 681-5600|
|Ventura (805) 654-2813||Ventura (805) 477-1620|
|*Table Footer here…|
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.
Fact Sheet Roof Disclaimer Neighbor’s Release
Food Bagging Instructions Plant Disclaimer Others: _____________________
Preparatory Instructions Security Disclaimer Others: _____________________
We suggest that you notify nearby neighbors of the date of fumigation and to keep pets away during the fumigation.
Close off all sub area accesses days prior to the fumigation to prevent any animals from entering.
[ ] Owner / Agent (signature) _____________________________ Date:______________________________
[ ] Occupant(s) (signature) ____________________________________________________________________
THE OWNER, OCCUPANT, OR OWNER’S AGENT MUST HAVE ALL ITEMS ON THIS CHECKLIST
COMPLETED PRIOR TO THE FUMIGATION CREW’S ARRIVAL; FAILURE TO DO SO MAY RESULT IN POSTPONEMENT, CANCELLATION, AND ASSESSMENT OF A FEE OF $150.00 OR MORE.
1. Remove all people and pets from the property. Pets may not be left in the backyard during the fumigation process. Notify your neighbors who may have cats, of the upcoming fumigation dates and close off all sub-area accesses to your property well in advance of the fumigation dates to prevent any animals from entering the space.
2. Remove all interior plants and those under patio covers or on attached decks/balconies. Trim back all trees, bushes, ivy, and other vegetation at least 12″ around the perimeter of the property. Detach climbing or trellised plants. Pull back all decorative bark or rocks. Heavily water plants in close proximity to the property the day before the fumigation to protect the root system. Attached plants or those in close proximity may have to be covered or may be damaged during the process. We assume no liability for any such damages.
3. Remove or bag all food, feed, drugs, or medicinals that are not sealed in glass, plastic. or metal bottles, jars. or cans with the original manufacturer’s airtight seal intact. This includes items in the refrigerator and freezer, medicines, spices, and opened liquor bottles. Only special NYLOFUME® bags may be used for bagging. See the food bagging instruction sheet for specific details. Improperly bagged or unbagged ingestibles will be bagged by the fumigation crew at a charge of $20.00 per bag.
4. Provide a complete set of keys to your property and provide instructions on where you would like the keys left upon completion. Keys must provide access to all areas within the structure being fumigated including garages and rooms that are normally locked. Any vehicles left inside must have the windows down and trunk and glove compartment opened_ File cabinets. desk drawers, etc… must be left unlocked to allow for inspection and proper aeration. Large or walk-in safes must be emptied then left unlocked, or you must make specific arrangements with our company to inspect them in advance and to clear them upon completion.
5. Ensure electricity and water is on at your property for the entire duration of the fumigation. Turn off air conditioning units. Turn off exterior lights and those that are on timers. Turn off burglar alarms or make specific arrangements with our company on how the alarm may be set.
6. Ensure natural gas service is shut off by the gas company prior to fumigation. Normally, our company schedules gas shut off for customers serviced by Southern California Gas Company and San Diego Gas & Electric. Customers serviced by others must schedule shut off directly and verify it is to occur no later than AM on the morning of the scheduled fumigation. The required lead time varies; please contact your gas service provider well in advance. In addition, unless otherwise advised, all customers must schedule their own gas restoration appointment. This must be done at least one working day in advance. Customer service numbers are provided for your convenience. To receive priority scheduling, contact your gas company as early as possible and tell then: you are having service restoration for fumigation. Upon arrival, the gas company technician will request the Notice of Re-Entry we leave at the main entrance and will need interior access. The technician will inspect appliances and relight pilots; any improperly venting appliances may require a contractor to be corrected.
Southern California Gas: (800) 427-2200 Long Beach Gas Department: (562) 570-5700
San Diego Gas & Electric: (800) 411-7343 Southwest Gas Company: (760) 241-9321
7. Remove all baby mattresses and change stations. Remove all plastic covers enveloping other mattresses.
8. Leave all drawers, cabinets and storage areas slightly open. Clear away Storage or items from windows to allow access.
9. Remove all valuables from the property. We do not provide on-site security. As such, neither the prime contractor nor our company shall be responsible for any loss or damage due to burglary, theft, vandalism, or other acts of third parties. For general information. windows must be left open to allow proper ventilation of your property. We take measures to deter access: however, these measures will not prevent unlawful entry by determined criminals. We encourage you to consider contracting on-site security for further piece of mind during the process.
10. Obtain written authorization from your neighbor(s) if tenting will require entrance/access into your neighbor’s yard. If your neighbor’s plants are in close proximity to the structure being covered, they will need to be cleared back and we will need a signed plant disclaimer as well. Advise your neighbor their pets must be removed or tied up during the entire duration of the fumigation. Your inspector will provide you with the necessary neighbor’s release and plant disclaimer to have signed. If not, please inquire with them in advance; if we are required to access a neighbor’s yard, we cannot proceed without written, signed authorization from that neighbor.
11. Provide an emergency phone number on line 4 on the front of this form. This is a number where you may best be reached while you are away from your home during the fumigation process.
12. Contact our company with any questions or concerns before, during or after the fumigation. We may be reached at (310) 675-6200 or for emergencies after hours at (562) 598-6270.
Terms, Conditions and Liabilities
A. Our company provides a time call for every job, however our crews perform several jobs in various locations daily. Each job presents its own unique challenges and our crews are also subject to southern California’s traffic. Thus, any time call provided is an estimate; we will make every effort to advise you if we are running behind. Further, we do not wish to inconvenience you by having you wait for our arrival. As an alternative, please consider providing the keys and notices in advance and leave with the assurance that your property will be properly fumigated and safe for re-entry upon your return.
B. Inclement weather may cause postponement. Many properties can be fumigated in the rain, but heavy winds are more problematic. We make every effort to stay on schedule; however, we must have full autonomy in making such decisions as they are affected not only by the likelihood the job will remain intact, but also by the safety of our crews. If your fumigation is postponed, we will attempt to advise you immediately.
C. Our licensed fumigators are responsible for verifying that occupants performed their interior preparations as directed and in a manner consistent with the fumigant product label. However, missed food or interior plants that were not removed remain the prime responsibility of the occupant. We can assume no liability for those items missed by the occupant and subsequently damaged or rendered useless as a result of the fumigation process.
D. As noted above, WE DO NOT PROVIDE ON-SITE SECURITY. As such, our insurance does not cover, and we will not be responsible for any loss or damage due to burglary, theft, vandalism, or other acts of third parties.
E. The roof covering and area below must be walked on and damages may occur. This includes consequential damage that may arise later. damage to attached gutters. wiring, patio and awning covers, solar heating panels and related plumbing. In the case of most tile roofs, THERE IS ALWAYS SOME DAMAGE. Although the utmost care will be utilized, we can assume no liability for such damages.
F. The fumigation process often requires the use of masking tape and spray adhesive to seal the tarps. When applied to stucco and painted surfaces where the surface is cold, oxidized or the paint has been improperly applied, peeling and chipping will occur. Residue from the adhesive may result in discoloration on painted or stucco walls. This is an inherent process and we can assume no liability for such damages.
G. During the tenting process, antennas and/or satellite dishes may be covered, moved or taken down. Normally, we request that these items be removed prior to the fumigation. However, if left in place, we can assume no liability for any damages that occur, or, more likely. any adjustments that must be made to the antenna or satellite dish to improve reception.
H. Due to the fragile nature in which mobile homes are constructed, some damage may occur to carports, roof rails, roofs, or siding. Although utmost care will be taken, we can assume no liability for such damages.
I. All exterior doors (including water heater cabinets) must be lockable. If no hasp or other interior/exterior locking device exists, state law requires nailing these doors shut. If no other adequate locking means is provided, and the fumigation licensee is required to nail a door shut, we assume no liability for resulting damages to include those to the door and doorjamb.
THIS OCCUPANT NOTICE MUST BE SIGNED, FRONT AND BACK. AND BE IN THE POSSESSION OF OUR CREW AT THE JOB SITE IN ORDER TO FUMIGATE. IF YOU HAVE BEEN INSTRUCTED TO LEAVE A COPY ON SITE, PLEASE LEAVE THE ORIGINAL SIGNED COPY.
___________________________________ ___________________________ _________________________
Signature Title Date