HomeMy WebLinkAboutWaiver - 601 MAIN STREET 10/22/2015 i
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The school,day care center,or school aged child care program listed belowhas determined that a human health
emergency pest problem Wdsts making necessary the use of a pesticides)not otherwise allowed under the
Massachusetts Pesticide Control Act, In addition,the emergency nature of the past problem standard written notification until after the emergency treatment. Further,the school,day care center,or nptin -aged
child care program listed below requests formal approval of a single-use waiver in accordance day wacerkte exempting
(Note:School refers to school,day care center,or school aged child careprogram) ce with above statute.
I. GENERAL INFORMATXON(Applicant must coma let 1
p e p®ase ' t)
NAME OF SCHOOL:
.ADDRESS:
CITY/TOWN-,
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I AX NUMBER: fy
E-MAIL ADDRESS:
NAME OF PERSONREQUESTINGEIVIERGENCY WAVER:
�AN IPM PLANTS O.NFIL�E*(effective* Sw�*�µ���
II.)3WR"BNCY INFORMATION(Applicant should describe the emergency as well as any other method(a)
W16d to solve the problem) method(a)
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Applicant must answer(yes or no)r rdigg the emergency situation
Doss the pest problem pose an immediate threat to human health?
rS NO
Arc,there any viable alternatives that could be used in place of pesticides?
to solve the pest problem?
.�..�YES !/ NO
FA;K THIS FORM TO YOUR MUMCIpAL BOARD OF HE
ALTH OR TO THl3 p T ,OF
AND AGRICULTURE AT(61�626-185 . COPIES OF T)Ciis P OY D EMERGENCY WAIVER(pages I
�c 2)MUST BE MAINTAINED By THE PEST MANAGEMENT pROFESSIONAL EMER
P03SEg9ION OF THE PA p AT THE TIME OF TREATIIMNT, �Mp)AND BE IN TId$
1smorgonpy Walver Form Application Page 1 of
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111.APPLICANT COMMITMENT[(Applicant must describe potential cause of the pest problem and list future
ArtiOhd thAt will be tamed to prevant this problem(if applicable)
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Applicant must ensure all requirements listed below are met as a condition of this approval
(Check Misr)
7-warning signs will be posted near and along perimeter of treatment
? warning signs will remain for at least 72 hours
? standard written notification provided prior to or after emergency
? emergency documentation maintained on site
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or Board of Health or De artment of Agricultural Resources Use Only)
A SINGLE-USE WAIVER IS APPROVED FOR EMERGENCY PESTICIDE TREATMENT
Al>provedFor;
Name of S ool
For Control of:
List Pest(s)
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For the use or:
List Trade Name and Ac ve Ingredient of Pesticide EPA Reg&
Date Approved:
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Approved by;
Name Title Date
Telephone: C-- f_ 0
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WARNING; 271is forte"wsl be signed and approved by the appropriate parties .Board ofHealtlt(I,IOh)or Massachusetts
De
parhttent ofA,gri'cullaral,Resoatreas(DAR)before an application Can take place.
FAX THIS FORM TO YOUR MUNICIPAL BOARD OF HEALTH OR TO THE DEPARTMENT OF AGRI-
CULTURAL RESOURCES AT(617)626-1850. COPIES OF THIS AMO—W EMERGENCY WAIVER(pages 1
&1)MUST BE MAINTAINED BY THE PEST MANAGEMENT PROFESSIONAL(PMP)AND BE IN THE
P013SESSION OF THE PMP AT THE TIME OF TREATMENT.
Fmergency Waiver Form Page 2 of 2
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