Get School Site And Child Day Care Facility Pesticide Use Reporting Form

SCHOOL SITE AND CHILD DAY CARE FACILITY PESTICIDE USE REPORTING STATE OF CALIFORNIA DPR-ENF-117 REV. 08/11 Page 1 of 2 APPLICATION YEAR BUSINESS REGISTRATION/LICENSE/CERTIFICATE BUSINESS/OPERATOR NAME STATE CITY BUSINESS ADDRESS School CDS /Child Day Care Facility OR Name Address AND Specify if School or Child Day Care Facility County Date Time Application Completed DEPARTMENT OF PESTICIDE REGULATION PEST MANAGEMENT LICENSING BRANCH Location or name from list on back Manufacturer Name of Product Applied ZIP CODE EPA/California Registration Number from Label include alpha code if possible BUSINESS PHONE NUMBER Amount Used and check one unit of measure School LB Day Care OZ OZ PT QT vol* wt. L GR QT GA ML KG vol* GA wt. ML KG LB OZ REPORT PREPARED BY Report must be submitted to the Department of Pesticide Regulation P. O. Box 4015 Sacramento CA 95812-4015 OZ OZ DATE PT QT Code from list on back TYPES OF PEST CONTROL CODES Code 10 - Structural Pest Control*. includes pest control work performed within or on buildings or other structures Code 30 - Landscape Maintenance Pest Control*. includes pest control work performed on landscape plantings around buildings Code 40 - Right-of-Way Pest Control*. includes pest control work along roadsides power lines median strips etc* Code 50 - Public Health Pest Control*. includes pest control work performed by or under contract with State or local public health or vector agencies Code 80 - Vertebrate Pest Control*. includes pest control work performed by public agencies or work under the supervision of the State or county agricultural commissioner Code 91 - Nonfood/Nonfeed Fumigation*. includes pest control work performed on commodities such as mattresses furniture etc* Code 100 - Regulatory Pest Control*. includes pest control work performed by public employees or contractors in the control of regulated pests LOCATION CODES Administration Bldg Athletic Field Auditorium Bldg Exterior Cafeteria/Kitchen Classroom Gymnasium Hardscape parking lot sidewalk etc* 9 Landscape indoor 10 Landscape outdoor 11 Library Locker Room Multipurpose Room Playground Pool 16 Restroom 17 Vehicle 18 Multiple Locations 19 Other Please indicate. 08/11 Page 1 of 2 APPLICATION YEAR BUSINESS REGISTRATION/LICENSE/CERTIFICATE BUSINESS/OPERATOR NAME STATE CITY BUSINESS ADDRESS School CDS /Child Day Care Facility OR Name Address AND Specify if School or Child Day Care Facility County Date Time Application Completed DEPARTMENT OF PESTICIDE REGULATION PEST MANAGEMENT LICENSING BRANCH Location or name from list on back Manufacturer Name of Product Applied ZIP CODE EPA/California Registration Number from Label include alpha code if possible BUSINESS PHONE NUMBER Amount Used and check one unit of measure School LB Day Care OZ OZ PT QT vol* wt. L GR QT GA ML KG vol* GA wt. ML KG LB OZ REPORT PREPARED BY Report must be submitted to the Department of Pesticide Regulation P. L GR QT GA ML KG vol* GA wt. ML KG LB OZ REPORT PREPARED BY Report must be submitted to the Department of Pesticide Regulation P. O. Box 4015 Sacramento CA 95812-4015 OZ OZ DATE PT QT Code from list on back TYPES OF PEST CONTROL CODES Code 10 - Structural Pest Control*.