HomeMy WebLinkAboutNew Construction Termite Service Record 10-4-17N8W Construction Subte"',_,"nean Termite
Service Ro' cord
This form is completed b the licensed Pest Control Cqm an
Public reporting burden forth s collection o informations estimated to ave
searching existing data sources, gathering and maintaining the data needed,
its required to obtain benefits, HUD may not col)ect this information, and you
control number.
Section 24 CFR 200,926d(b)(3) requires that the sites for HUD' -Insured struct
builder to certify that an auth6riaed Pest Control company performed all requl
against infestation,for one year. Builders. pest control companies, mortgage li
use the information collected. The information Is not considered confidential,1
This report is subrnitted'for informational purposes to the builder on proposed
Infestation is specified by the builder, architect, or required by the tender, arch
All contracts for services are
Section 1:'General In
Company Name;
Company Address
Company Business License
FHAIVA Case No. (if any)
aacuon x: munoer ii
Company Name
the Pest Control company and builder,
(Pest Control
Section 3. Property Information � /
iS� tl 0 V e_ . SbVL r
Location of Structure (s) Treated (Street Address or Legal Description, c
Section 4: Service
Date(s) of service(s)
Type of Construction (More than one boK may be checked) SlE
Ch ak all that apply:
A. Soil Applied Liquid Termiticide �7
Brand Name of Termiticide�C�r.c-c }L 1 x EPA Regist
Approx. Dilution Approx, Total Gallons MIX Applied;
❑ S. Wood Applied Liquid Termiticide
Brand Name of Termiticide: EPA R6gis6
Approx, Dilution (%}: �� Approx. Total Gallons MlxApplle
C. Bait system installed
Name of System EPA Registration No. _
D. Physical Barrier System Installed
Name of System Attach installation infor
Service Agreement Available? C3 Yes No
Note: some state laws require service agreements to be issued. This farm
Attachments (List)
Comments
Name ofApplicator(s) _�`�"� [�r''/✓
The applicator nas used a product In accordance with the product label and
regulations. 1
Authorized signature ...
Warning: HUD will prosecute. false claims and statements, Conviction msy result in
OMB Approval No, 2502,0525
(exp. 02129/2012)
10 minutes per response, inclthe uding t e time for reviewing instructions,
rtion
not rcomequired to compete tana his form I unless t of Idisp displays acurrently v. This s idtion
OMB
must be free of termite hazards, This information collection requires the
treatrtlentfor termites, and that the builder guarantees the treated area
ors, homebuyers, and HUD as a record of treatment for specific homes will
,fore, no assurance of confidentiality is provided,.
w) construction cases when treatment for prevention of subterranean termite
t, FHA, or VA.
stated otherwise.
Company Phone No, 7Z r
No, V v
State and Zip)
❑ Basement . ❑ Crawl ❑ Other
�Q/0
Treatment completed on exterior: 0 Yegj NO
Number of Stations Installed
(required)
not preempt state law,
Certification No. (if required by State law) � Z
requirements, All materials and methods used comply with state and federal
Date
andlor civil penaltles, (18 U,S,C. 1001, 1010, 1012; 31 U,S.0. 3729, 3s02)
form HUD.MPMA-0943 (081=8)