Monthly Report of Wood Destroying Insect Control Work

Mississippi Department of Agriculture & Commerce — Bureau of Plant Industry

Report Information

#if("#text(#field(17342))" != "Yes")#endif

Company Name

#field(14183)

Contact

#field(17341) #field(17340)

Contact Phone

#field(17321)

Contact Email

#field(17322)

Licensee

#if("#text(#field(17342))" == "Yes")Same as Contact#endif#if("#text(#field(17342))" != "Yes")#field(17319) #field(17320)#endif

Licensee Phone

#field(17706)

Licensee Email

#field(17707)

PHYSICAL ADDRESS

#text(#field(14184))#if(#field(14185))
#text(#field(14185))#endif
#text(#field(14186)), #text(#field(14187)) #text(#field(14188))

MAILING ADDRESS

#if("#text(#field(14190))" == "Mailing address is same as physical address")Mailing address is same as physical address.#endif#if("#text(#field(14190))" != "Mailing address is same as physical address")#text(#field(14191))
#if(#field(14192))#text(#field(14192))
#endif#text(#field(14193)), #text(#field(14194)) #text(#field(14195))#endif

Report Month / Year

#field(14197) #field(14198)

Work Performed This Month

#field(14200)

#if("#text(#field(14200))" == "Yes")

Termiticide Inventory

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Item	Brand Name	Formulation	Beginning	Used	Purchased	End
#section_row_number	#text(#field(14204))	#text(#field(14205))	#text(#field(14206))	#text(#field(14207))	#text(#field(14208))	#text(#field(14209))

Treatment Records

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Treatment Record #section_row_number

Customer

#text(#field(14215)) #text(#field(14216))

PROPERTY ADDRESS

#text(#field(14217))#if(#field(14218))
#text(#field(14218))#endif
#text(#field(14219)), #text(#field(14220)) #text(#field(14221))

PROPERTY MAILING ADDRESS

#if("#text(#field(14223))" == "Property mailing address is same as physical address")Property mailing address is same as physical address.#endif#if("#text(#field(14223))" != "Property mailing address is same as physical address")

#text(#field(14224))#if(#field(14225))
#text(#field(14225))#endif
#text(#field(14226)), #text(#field(14227)) #text(#field(14228))

#endif

Contractor / Owner

#text(#field(14230))

Subdivision / Lot

#text(#field(14231)) / #text(#field(14232))

Date of Treatment

#text(#field(14233))

Treatment Type

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Structure Type

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PRE-CONSTRUCTION OR PRE-TREAT PERIMETER FINAL GRADE OR WOOD TREATMENT TERMITE ONLY		EXISTING/POST CONSTRUCTION OR RETREAT/EXISTING CONTRACT OR SPOT TERMITE ONLY		DILUTE PESTICIDE APPLIED OR TERMITE BAIT INSTALLATION
Horizontal Barrier Treated (Sq. Ft.)	Vertical Barrier Treated (Linear Ft.)	Linear Ft. Treated @ 4 Gal per 10 Linear Ft.	Linear Ft. Treated @ 2 Gal per 10 Linear Ft.	Pesticide Brand Name OR Baiting System Brand Name	Percent Finished Solution	Total Gal Applied OR # of Bait Stations Installed
#text(#field(14239))	#text(#field(14242))	#text(#field(14240))	#text(#field(14243))	#text(#field(14241))	#text(#field(14244))	#text(#field(14245))

#section_rows_end #endif

Submission ID: #submit_id