HomeMy WebLinkAboutTermite Service RecordNew Construction Sub$er>i-,a"Aean Tormfte
Service Record
This form is completed by the licensed Pest Control CornOanv
r
f�i'?'t .�'�
! 1�l 1� �5�✓i OMB Approval No, 2502 0525
v J (axp, 0513012018)
searching existing data sources, gathering and maintaining the datneeded, aand Completing Sand revier ewing the collection olf infome rmation. 'This information
Ifs requlred'to obtain benefits. HUD may not collect this Information, and you are not required, to complete this form, unless it displays a currently valid OM19
control number.
Section 24 CFR 200,926d(b)(3) requires that the sites for HUD insured structures must be free of termite hazards, This Information collection requires the
builder to certify that an authorized Past Control company performed all required treatment for termites, and that the builder guarantees the treated area
against infestation for one year Builders, pest control companies, mortgage lenders, homebuyers, And HUD as a record of treatment for specific homes will
use the information collected, The information is not considered confidential, therefore, no assurance of confidentiality is provided.
This report is submitted for informational purposes to the builder on proposed (new) construction cases when treatment for prevention of subterranean termite
infestation is speclfled by the builder, Architect, or required by the lender, architect, FHA, or VA.
Allcontracts for services are between the Pest Control company and builder, unless stated otherwise.
Section 1: General Information (Pest Control Company Information)
Company Name; Ameron Pest Control
CopanyAdd.reas 519 s easy St
Company Business License No. JB 191692
FHA/VA Case No. (if any)
City Sebastian
state FL zip 32958
Company Phone No_ 772-388-8828
Section 2: Builder Information
Company Name Phone No.
Section3: Property Information
)`
Location of Structure (s) Treated (StreetAddress or Legal Description, City, State and zip) //
r
Section 4: Service Information
1
Date(s) of Servica(s)
Type of construction (More than one box may be checked) Slab [] Basement C] Crawl Q other
Check all that apply:
A. Soil Applied Liquid Termiticide
Brand Name of Termiticide: Crosscheck plus EPA Registration No. 279-3204-10404
Approx. Dilution (%):.12 Approx. Total Gallons Mix Applied; Treatment completed on exterior: Yea.
a, Wood Applied Liquid Termiticide
No
Brand Name of Termiticide:_ FPA Reglstration No.
Approx. Dilution (%): Approx. Total Gallons MlxApplied:
J C, Belt system Installed
Name of System_ - 1-PA Registration No. Number of Stations installed��
D. Physical Barrier System Installed
Name of System
!!��
Attach Installation Informatlon (required)
tr
Service Agreement Available? Yes No
Note: Some state laws require service agreements to be Issued, This form does not preempt state law.
Attachments (List)
comments
Name ofApplicator(s) Matthew Helton
Certification No. (if required by State law) JE209098
The applicator has used a product'in accordance with the product label and state requirements. All materials and methods used comply with state and federal
�Aulhorizad
regulatons. Slgnat pate _&I//'�z
Wamingt HUD will prosecvte false claims and statement.. Conviction may rasult in criminal and/or civil penalties, (18 U.S,C,1001, 1010-1012; 31 U.S.C. 9729, 3902)
form HUD-NPMA-99-13 (0812oos)