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HomeMy WebLinkAboutWaiver - 601 MAIN STREET 9/30/2015 C S4 e AA- PA�� .EMERGEPTCYWAIiIETtAI'PLTCATION' � l "' .l�y��,��� FC)R PEST�C�DE USA*IN SCI nn S Dt1I'C CE RS OR CHOl1 'AYE CHMh C P DIl e-h:4MS' Theschool,day care center;or scliaoI aged childcare ro emergency P ,graz�i listed below has deterniired that a-human health cy pest prabletu exists making rtecessar$y the use of a pesticide(s)not otherwise altawed:uzzder the Massachuset#sFesticide Coiztrol Act. In addition:the emergencynature ofthepestpr6blem warrants exempting, .child aril written not fication until after the emergency treatment. Further,:the school,day care center,.ar school-aged child°care program'Izsted below requests forircal approval of a single-use,waver in accordance with above statute. {Note:;Sefu al refers to sell ool,clay care center,or such of°aged clzild care program) I GENERAL ?4RIVIATIOPI Applicant must-complete-pleas a print) NAME,OF SCHOOL, �..: e - - _ ADDRESSt CI;TY/TOW - TELEPHONE: , FAN:NUiYIB:ER: �~ y E ADI?RESSs �� i lt� l c �1v2 C' NAME OFP.EPSONREQUESTING:EMERGENCX WAIVER, AN IPM PLAN IS ON FILE: (effective I 1-t-QI)? L' YES NO II.EMERGBNCY`INFOXNIATION used to:solvathe problem) (Applicant sltauld'describe the ainergency as well as any o or methods) Applicant must answer(yes or no)regarding the emergency situation y -'Y�.-I� l ;Does:the pest problem-pose'an ia=ediate threatto hutriari health? YES NO Are there:any viable alternatives that could be used in place of pesticides? to solve the pest:problem? -YES NO FAX TMS IFOItM TO YOUR MUNICIPAL HOARD OF HEALTH`OR TO TIM DEPARTMENT OF AND AGRICULTURE.<AT(611}626-1950. COPIES OF TMS APP ROVED EMERGEIrTCY WAIVER(pages 1. .2)MUST:BE MAiNTAII�TF3D BY THE PEST MANAGEMENT.PROFESSI OF T ONAL(PMP)ANI BE IN THE POSSESSION HE PAD AT TIM TIME OF TREATMENT: Emarg,mcy Waiver FonnAjplicatian page 1 ofr` III,APPLICANT CtDNLMITMENT[{Applicant mush'descr�l3e potential cause of the pest problem and list future. actiotxs.thatwili b c used t. this problem(if applicable)] Applicant;must ensure All requirements listed below axe met as a condition of this app'ro`val (Check Usi) -vwamingsigns:w ll be posted near and.along perimeter of treatment warn og si 3$will zemain.for st:least 72 hours- 1. standatd tMtten notif oatian provided prior to or after enlergericy ? :emergency'dosunientat on i is nWned on site, (F'or$oaYd:of Health oz De artrient of A ricultural Resouroes IIse©nly) A SINGEf LE=US/E`4'VAIV P,is A pR±QV.Efi FOR EM> RGENCY PESTICIDE TREATMENT Approved // the of Sch/ooi For Control oh LI stPest{s}, � For the use of: f i 7-i ade Name and Active Ingredient (Pesticide EP.A Reg#. Date A'__,ppr aved: P Appruved.bs IX 1� Nanie Title Date CIV 7CeCe tonei WARN&G•17:YS f orm lutist he signed and approved by the appropr ate aries Board o f lfeall(BO H or;Massachresetts Pgartnreni ofAgricultura[Resources(DAR)before an applicado.n..can talfE place.. FAX THIS FORM TO YOUR MUNICIPAL BOARD OF HEALTH UR TO THE DEPARTMENT OF AGE CULTURAL RESOURCES AT{617)G26-IS50, COPIES()F THIS APPROVED EMERGE TI'Y'WAIVER{pages:l &2)MUST MAINTAINED BY THE I BEST MANAGEMENT PROFESSIONAL(PMP)AND BE IN THE POSSESSTON OF THE P1VII'AT THE TIME OF TREATIVIERIT. Emergency Wai er Form Page 1 of 2