Atch_28_-_Termite_Application_Form.pdf

Company Name:

Address:

Phone Number:

Fax Number:

Emergency Contact Number:

Project Information

Date: Technician:

Time:

Standing Water on Site □ Yes □ No Company Project Number:

Precipitation □ Yes □ No Scott AFB Project Number:

Soil Frozen □ Yes □ No

Project Name:

Project Location:

Building Number:

General Contractor:

Contact Name/ Number:

Calculations Information

Dye Specified □ Yes □ No

Dilution Calculation Percent (fill in) Specified Percent (fill in)

Slab: gallons times Square Feet equals gallons used

Foundation Walls

Inside gallons times Depth (feet) times Lin Feet equals gallons used

Outside gallons times Depth (feet) times Lin Feet equals gallons used

Chemical Used:

EPA Regulation Number:

Manufacturer:

Application Information

Dilution: (circle one) 0.25% 0.50% 0.75% 1.00% Other

Square Foot of Slab:

Soil Type encountered: □ Fill Soil □ Clay □ Gravel □ Rock

Gallons Used:

Lineal Feet of Foundation: □ Outside □ Inside

Depth Below Grade of Penetration:

Top Of Footing Below Grade:

Spacing for Rodding: inches on center

Trenching □ Yes □ No

Dimensions of Trench Width Depth

Continuous □ Yes □ No Gallons Used

Soil Moisture: Gallons of Undiluted Concentrate Used:

Applicator Name: (printed)

Illinois License Number:

Signature

Soil Treatment Application Form