AES-23-42 PRE-TREATMENT NOTIFICATION FORM ADA

PRE-TREATMENT NOTIFICATION FORM
Complete all required sections of the pre-treat notification form to comply with LAC 7:XXV.141.E.4.

Changes to any details of a previously submitted pre-treatment notification, (i.e. time, address, lot, etc.), must be submitted on a new pre-treat notification form. Select ‘Revision’ under notification status and add additional details or other changes to the ‘Other Information’ section.

Cancellation of a previously submitted pre-treatment must be submitted on a new pre-treat notification form. Select ‘Cancellation’ under notification status and any additional details to the ‘Other Information’ section.

All fields required unless otherwise noted.
COMPANY NAME*
PLACE OF BUSINESS PERMIT NUMBER*
COMPANY ADDRESS*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
COMPANY PHONE NUMBER*
Enter numbers only
COMPANY EMAIL*
example@example.com
TREATMENT DATE*

MonthDayYear
TREATMENT TIME

Hour Minutes

AM/PM Option
NOTIFICATION STATUS*

INITIALREVISIONCANCELLATION
TREATMENT TYPE*

FULL PRE-TREATMENTSUPPLEMENTAL PRE-TREATMENTBORATE PRE-TREATMENT
TREATMENT PROPERTY ADDRESS*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PARISH
BUILDER OR CONTRACTOR*
DIRECTIONS TO PROPERTY SITE (Please list the main road subdivision or building is off of.)*
ESTIMATED SQUARE FEET OR LINEAR FEET TO BE TREATED*
NUMBER OF STRUCTURES*
OTHER INFORMATION/REVISION/CANCELLATION INFORMATION (IF APPLICABLE)
SUBMITTED BY*
PRIMARY LICENSEE NAME*
PRIMARY LICENSEE NUMBER*
Date

MonthDayYear
Date
Hour MinutesAM/PM Option
Should be Empty: