Community Name

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Address of Structure to be Fumigated (Required)

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Webinar Recorded Watch Recording

Vacate ...

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Personal Information

Unit Information

Checklist & Access

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State:

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Owner/Agent Name (Required)

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Contact Phone (Required)

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Occupant Name

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Occupant Phone

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IF YOU ARE AWARE (Required)

If you are aware of any conduits, pipes, common drains, central vacuum systems, air ducts, or any other construction elements that would allow for the passage of a fumigant from the structure to be fumigated to any other adjacent or adjoining structures that are not to be fumigated, please describe in detail:

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CHLOROPICRIN WILL BE USED AS A WARNING AGENT

Start Date of Fumigation

End Date of Fumigation

Prime Contractor: ACCURATE TERMITE & PEST CONTROL	PR#: 4527	Emergency Number: (844)468-2687
Fumigation Contractor: ...	PR #: ...	Emergency Number: ...
Target Pest(s): Drywood Termites		Fumigant Brand Name: VIKANE
Active Ingredient: Sulfuryl Fluoride

IMPORTANT READ CAREFULLY

THIS STRUCTURE WILL BE FUMIGATED WITH A LETHAL GAS ON THE DATE(S) INDICATED ABOVE. ALL PERSONS AND ANIMALS MUST VACATE THE STRUCTURE ON OR BEFORE ARRIVAL OF THE FUMIGATION CREW.
UNDER NO CIRCUMSTANCES CAN ANYONE ENTER THE STRUCTURE 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...

For Health Question

Country Health Department	County Agricultural Commissioner	Poison Control Center	Structural Pest Control Board
See Page 2 on the PDF for phone numbers	See Page 2 on the PDF for phone numbers	1-800-222-1222	1-800-737-8188

WE SUGGEST YOU NOTIFY YOUR NEIGHBORS OF THE START AND END DATE OF FUMIGATION AND TO KEEP PETS AWAY DURING THE FUMIGATION. CLOSE OFF ANY ACCESS TO THE SUBAREA TO PREVENT PETS FROM ENTERING.

I hereby acknowledge receipt of a copy of this document and the information contained herein...

Signature (Required)

Please sign the document before proceeding.

Signed By

Checklist

Remove all people from the property to be fumigated.
Remove all pets (including fish and birds)...
Remove all interior or exterior plants...
Remove all vehicles and boats from the garage/carport if included...
Remove all mattresses enveloped with plastic covers...
Bag or remove all foods and medicines...
Damage may be unavoidable to plants close to the building...
The occupant must turn off any air conditioning unit...
The occupant must leave attic covers...
We must have access to all areas within the structure...
PLEASE MAKE ARRANGEMENTS TO PROVIDE A SPARE KEY...
We will assume no responsibility for any damage or misaligned antennae...
To ensure complete gas ventilation, the fumigator may sometimes have to open your drawers...
Although your Homeowner’s Insurance should cover burglary...
ELECTRICITY MUST BE TURNED ON TO POWER FANS...
I/We the undersigned have read reviewed and agree to all the provisions...
I/We shall absolutely observe and abide by all reasonable precautionary measures...
Satellite dishes or parabolic antennas may be knocked out of alignment...
If the fumigation process requires a SCG/PG&E/SDG&E technician...

I have reviewed the checklist and disclaimers (Required)

I have reviewed the checklist and disclaimers

You must agree to the checklist before proceeding.

Print Name (Required)

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Unit Access Information (Required)

How can we obtain access?

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Please pay attention to the following resident check and important disclaimer

READ CAREFULLY- State Law Requires your signature. It is the responsibility of the owner/tenant, or owners agent to have all the items on this checklist done prior to crew arriving; failure may postpone the fumigation.

Chemical: Vikane

The crew's estimated time of arrival is approximate only...

On the first day the structure is covered and the fumigant introduced...

Under no circumstances may anyone enter the structure until it has been declared safe for re-entry...

If you experience symptoms of dizziness, headache, nausea, reduced awareness...

Structural fumigants are colorless, odorless and do not affect paints, or finishes...

Terms, Conditions and Liabilities.

We hope that your fumigation will be problem free...

Climbing plants, trellises and vines must be removed or detached...
If rain or high winds start after the fumigation has begun...
Forcible entry, if necessary, when all keys are not provided, will result in damage...
The use of masking tape used during a "tape and seal" fumigation may result in the peeling of paint...
While we are concerned about your property, some of the following may be unavoidable...
If additional time is needed for safety reasons or a longer exposure period...
Gas must be turned off. NATURAL GAS: If you are a SCG/PG&E/SDG&E customer...
We do not provide on-site security during the fumigation procedure...
All exterior doors (including water heater cabinets) on the building being fumigated...
Accurate Termite and Pest Control and Next Generation Fumigation will not be liable for any harm...

THIS NOTICE HAS BEEN PRINTED IN THE ENGLISH LANGUAGE...

By signing my name above, I am stating that I have read all statements and conditions...

Signature & Complete (Required)

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Signed By

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Community Name

IMPORTANT READ CAREFULLY

For Health Question

Checklist

Terms, Conditions and Liabilities.

Update Unit Access Information

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Community Name

IMPORTANT READ CAREFULLY

For Health Question

Checklist

Terms, Conditions and Liabilities.

Update Unit Access Information

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