Cal. Code Regs. Tit. 16, div. 19, art. 4, form 43M-48
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)
Fumigants proposed to be used: []Methyl Bromide []Sulfuryl Fluoride: __________ (Product Name)
[]Other(s) __________
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 structure?
YES() NO() __________
__________
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, 2005 Evergreen Street, Ste. 1500, Sacramento, CA 95815.
FOR HEALTH QUESTIONS:
| COUNTY HEALTH DEPARTMENT | COUNTY AGRICULTURAL COMMISSIONER | POISON CONTROL CENTER | STRUCTURAL PEST CONTROL BOARD |
| PHONE # | PHONE # | PHONE # | PHONE # |
(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 open access to the subarea to prevent pets from entering.
[ ] Owner/Agent (signature) ____________________________________________________________ Date __________
[ ] Occupants(s) (signature) ____________________________________________________________
___________________________
___________________________
Cal. Code Regs. Tit. 16, div. 19, art. 4, form 43M-48