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 only
COMPANY EMAIL*
example@example.com
FUMIGATION DATE*

MonthDayYear
START TIME*

Hour Minutes

AM/PM Option
NOTIFICATION STATUS*

INITIALREVISIONCANCELLATION
TREATMENT PROPERTY ADDRESS*

Street Address

Street Address Line 2

CityState / Province

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

DRYWOOD TERMITESPOWDER POST BEETLEFORMOSAN TERMITESOTHER
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 only
PRIMARY LICENSEE EMERGENCY PHONE NUMBER*
Please enter a valid phone number.
Date

MonthDayYear
Date
Hour MinutesAM/PM Option
Should be Empty: