AES-23-46 FUMIGATION NOTIFICATION FORM ADA

FUMIGATION NOTIFICATION FORM
Complete all required sections of the fumigation notification form to comply with LAC 7:XXV.147.B.1.

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

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

NOTICE SHALL BE RECEIVED BY THE DEPARTMENT AT LEAST 24 HOURS PRIOR TO STRUCTURAL FUMIGATION
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 onlyFormat: (000) 000-0000.
COMPANY EMAIL
example@example.com
FUMIGATION DATE

MonthDayYear
START TIME

Hour Minutes

AM/PM Option
NOTIFICATION STATUS
TREATMENT PROPERTY ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PARISH
PROPERTY DESCRIPTION OR CONSTRUCTION TYPE
TARGET PEST

OTHER
LOCATION OF PEST
EVIDENCE FOUND
FUMIGANT USED
VISIBLE ACTIVITY
OTHER INFORMATION/REVISION/CANCELLATION INFORMATION (IF APPLICABLE)
SUBMITTED BY
PRIMARY LICENSEE NAME
PRIMARY LICENSEE PHONE NUMBER
Enter numbers onlyFormat: (000) 000-0000.
PRIMARY LICENSEE EMERGENCY PHONE NUMBER
Please enter a valid phone number.Format: (000) 000-0000.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hour MinutesAM/PM Option
Should be Empty: