California Code of Regulations › Title 16 - Professional and Vocational Regulations › Division 19 - Structural Pest Control Board › Article 4 - Fumigation and Pesticide Use › Form 43M-48

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
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)
				  ____________________________________________________________
___________________________
___________________________