FMP Service Ticket ARIZONA WILDLIFE RESOURCE, LLC 3560 N Maya Rd • Eloy, AZ 85131 (520) 709-4861Date of ServiceMonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Frequency of Service(monthly, twice a month, quarterly, etc.)Customer NameBill to: Customer Other Bill to company or individualPlease enter name.Treatment Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Chemical Used Weevil-cide EPA REG #70506-13 Gopher Bait (Strychnine Alkaloid) EPA REG #5042-32 Check all that apply.Weevil-cide EPA REG #70506-13QuantityNumber of tablets% of Active IngredientFinished AmountIn gramsGopher Bait (Strychnine Alkaloid) EPA REG #5042-32% of Active IngredientFinished AmountIn gramsSign OffNOTESTechnicianCustomer SignatureTechnician SignatureWarning! PESTICIDES CAN BE HARMFUL. KEEP CHILDREN AND PETS AWAY FROM TREATED AREAS OF APPLICATION UNTIL DRY, DISSIPATED, OR AERATED. FOR MORE INFORMATION, CONTACT: VALERIE MOTYKA - BUSINESS LIC 32547 - PHONE (520) 709-4861 - EMAIL: WELOVEWILDLIFE@AZWILDLIFERESOURCE.ORG Δ