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STATE OF CALIR 41A ( DEPARTMENT OF PEST' =REGULATION <br /> MONTHLY SUMMARY PESTICIDE USE REPORT ENI v1ENT BRANCH <br /> PR-ENF-060(REV.08/08)Page 1 of 6 <br /> INSTRUCTIONS FOR COMPLETING THIS FORM ARE INDICATED BELOW AND ON THE REVERSE SIDE <br /> CITY Z P CODE PHONE NUMBER <br /> OPERATOR(FIRM NAME) [!DRESS <br /> e!5 <br /> 7y�COUN�TY�WHERE` <br /> OPERATOR ID/PERMIT NUMBER LICENSE NUMBER APPLIED CO TY NUMBER MONTH(YEAR OF USE TOTAL NUMB OF APPLICATIONS <br /> 1.Complete Columns A,B,C,and D for All Users <br /> 2.Complete Column E by using one of the following codes: <br /> Code 10 Structural Pest Control.....................................includes any pest control work performed within or on buildings and other structures. <br /> Code 30 Landscape Maintenance Pest Control.............includes any pest control work performed on landscape plantings around residences or other buildings,golf courses,parks,cemeteries,etc. <br /> Code 40 Right-of-Way Pest Control...............................includes any pest control work performed along roadsides,power lines,median strips,ditch banks,and similar sites. <br /> Code 50 Public Health Pest Control...............................includes any pest control work performed by or under contract with State or local public health or vector control agencies. <br /> Code 80 - Vertebrate Pest Control....................................Includes any vertebrate pest control work performed by public agencies or work under the supervision of the State or county agricultural commissioner. <br /> Code 91 - Commodity Fumigation(Nonfood/Nonfeed).....includes fumigation of nonfood/nonfeed commodities such as pallets,dunnage,furniture,burlap bags,etc. <br /> Code 100 Regulatory Pest Control.................................includes any pest control work performed by public employees or contractors in the control of regulated pests. <br /> 3. Complete Columns F and G,if use de$nsf fit one of the above codes <br /> A B C D E F G <br /> MANUFACTURER AND EPA/CALIFORNIA REGISTRATION NUMBER FROM LABEL TOTAL PRODUCT USED NUMBER OF CODE COMMODITY OR SITE ACRES/UNITS <br /> NAME OF PRODUCT <br /> APPLIED INCLUDE ALPHA CODE (Circle One Unit of Measure) APPLICATIONS TREATED TREATED <br /> 6 <br /> L( LB OZ PT QT GA <br /> QT GA <br /> LB OZ PT QT GA <br /> LB OZ PT QT GA f <br /> � L <br /> LB OZ PT QT GA <br /> LB OZ PT QT GA <br /> LB OZ PT QT GA <br /> LB OZ PT QT GA <br /> LB OZ PT QT GA <br /> REPORT PREPARED BY DATE <br />