Fumigation Management Plan for Burrowing Pests Treatment Date Month Day Year Certified Applicator Name & License # Valerie Motyka #32547 Hal Golightly #970169 Select AllApplicator Contact InfoProperty / Business NameOwner NameProperty Owner Email Owner Cell PhoneOwner Other PhoneSite / Field Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Emergency Contact InformationPolice Dept PhoneFire Dept PhoneHospital PhonePoison Control PhoneProduct InformationProduct NameEPA Reg#Formulation500 tablets per flaskManufacturerApplication Site InformationType of Fumigation Closed Burrow Open Burrow Type of Property Farm Golf Course Site suitable fumigation Yes No This field is hidden when viewing the formDate Inspected MM slash DD slash YYYY Tunnel / Burrow System more than 100 feet from inhabited structures. Yes No Site drawing included (with location of structures and general location of areas within flelds or pastures treated, if entire area was not treated.) Yes No Upload map of treatment area & label Drop files here or Select files Accepted file types: jpg, jpeg, png, pdf, heic, Max. file size: 512 MB. Pre-Application ChecklistTarget PestDosage per holeAll assisting persons informed of accident reporting and emergency procedures. Yes No Label, MSDS, and Applicator's Manual reviewed with all assisting persons. Yes No N/A (no assistants) All assisting persons provided and wear proper protective equipment - gloves. Yes No N/A (no assistants) Any nearby people notified of application. Yes No Have placards been placed? Yes No Application DateMonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Time Hours : Minutes AM PM AM/PM Temperature (° F)Wind direction and speedPost-Application ChecklistTotal amount of product usedAll burrows sealed after treatment. Yes No All assisting persons informed of and perform hand washing after treatment. Yes No Clothing and gloves aerated prior to laundering. Yes No Product returned to locked, secured area when not in use. Yes No Upload map of treated area and supporting photos. Drop files here or Select files Max. file size: 512 MB. Sign-OffCertified Applicator SignatureThis field is hidden when viewing the formDate MM slash DD slash YYYY Δ