Intergrated Pest Management

Intergrated Pest Management

Requested By: Name & Department

Building Name*

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Building Address

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Phone Number

Work Order Number

Date of Request

UO Contact: Name & Department

Room/Area*

Target Pest*

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If other, please describe:

Action Level

Observed Activity

Site Description:*

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Location Address

Interior or Exterior

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Requested Date of Use

Requested Time of Use

Purpose of Use

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Notification Instructions

Pest Contractor

Special Precautions

Requested Action

Applicator Name*

Applicators Phone Number

Address

Pesticide License Number*

Email

Pesticide Product Name*

EPA Registration Number*

Date of Use*

Amount of Undiluted Pesticide Product Used*

Method of Application*

Rate of Application*

Recommended Follow-Up Actions

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