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OCCUPANTS FUMIGATION NOTICE AND PESTICIDE DISCLOSURE
JOB ADDRESS___________________________________ CITY__________________________________________
[ ] Single Family Dwelling [ ] Multi Family Dwelling [ ] Other ___________________________________
Owner/Agent/Occupant _______________________________________________________________________________
Tel. No. ( ) _________________________ Emergency No. ( ) _______________________________________
Prime Contractor A-1 BONDED TERMITE, INC. Emergency No. ( 714 ) 502-9230
Fumigation Contractor A-1 Fumigation Inc. Emergency No. ( 562 ) 866-7535
Target Pest(s): [ X ] Drywood Termites [ ] Beetles [ ] Other(s)
Fumigants proposed to be used: [ ] Methyl Bromide [ X ] Sulfuryl Fluoride: VIKANE
(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:_____________________________
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 ( 800-876-4766 ) 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 ( See Above ) ; 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 COUNTY AGRICULTURAL POISON CONTROL STRUCTURAL PEST
DEPARTMENT COMMISSIONER CENTER CONTROL BOARD
213-250-8055 . . . . . LA 626-575-5466 . . . . . . .LA 800-876-4766 . . . . . .LA
714-834-4722 . . . . OR 714-955-0100 . . . . . . .OR 800-876-4766 . . . . . .OR STATE WIDE
951-358-5000 . . . . . RIV 951-955-3000 . . . . . . .RV 800-876-4766 . . . . . .RV 800-737-8188
800-782-4264 . . . . . SB 909-387-2105 . . . . . . .SB 800-876-4766 . . . . . .SB
(This section may be modified to include the information of geographical area served by the license.)
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.
Gas Company Information – Fumigant Fact Sheet – How To use Nylofume Bags or Know what needs to be bagged
We suggest that you notify nearby neighbors of the date of the fumigation and to keep pets away during the
fumigation. Close off any open access to the sub area to prevent pets from entering.
[ ] Occupant/Owner/Agent (signature)____________________________________________ Date_____________________
Print Name____________________________________________ Contact Number _______________________________