FUMIGATION NOTIFICATION FORM AES-23-46

NOTICE SHALL BE RECEIVED BY THE DEPARTMENT AT LEAST 24 HOURS PRIOR TO STRUCTURAL FUMIGATION
COMPANY NAME*
PLACE OF BUSINESS PERMIT #*
COMPANY ADDRESS*
COMPANY EMAIL*
example@example.com
Company Phone Number *
Please enter a valid phone number.
FUMIGATION DATE*

MonthDayYear
Date
FUMIGATION START TIME *

Hour Minutes

AM/PM Option
TREATMENT PROPERTY ADDRESS**

Street Address

CityState

Postal / Zip Code
Parish*
PROPERTY DESCRIPTION /CONSTRUCTION TYPE *
TARGET PEST*

DRYWOOD TERMITESFORMOSAN TERMITESPOWDER POST BEETLEOTHER PEST
LOCATION OF PEST*
EVIDENCE FOUND*
FUMIGANT USED *
VISIBLE ACTIVITY*
SUBMITTED BY*
PRIMARY LICENSEE NAME*
PRIMARY LICENSEE ID NUMBER*
PRIMARY LICENSEE ADDRESS*
PRIMARY LICENSEE EMERGENCY PHONE NUMBER*
Please enter a valid phone number.
FUMIGATION NOTIFICATION FORM
Date Submitted*

MonthDayYear
Date
Time Submitted*

Hour Minutes

AM/PM Option
Should be Empty: