Pest Inspection Form
Inspector Name
First Name
Last Name
Inspection Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time in
Time Out
Inspector certification #
Branch
Route
Customer #
Property Name
Please choose inspection frequency
Weekly
Monthly
Bi-Monthly
Quarterly
Semi-Annually
Annually
Work Order #
Please specify special service instructions
Material used for inspection
Pest Control Material Used
Please Select
Advance 375 Granular Ant Bait (Abamectin B1) 0.011% [499-370]
Advance Dual Choice Ant Bait (Abamectin B1) 0.011% [499-496]
Advance 388B Ant Gel Bait (Borax) 5.4% [499-492]
Ascend Fire Ant Bait (Abamectin B1) 0.011% [499-370]
Avert Roach Bait Stations (Abamectin B1) 0.011% [499-467]
Advance Roach Bait (Dinotefuran) 0.5% [499-507]
Avert Dry Flowable Bait (Abamectin B1) 0.05% [499-294]
Borid Dust (Boric Acid) 99% [9444-129]
Demand CS (Lambda-cyhalothrin) 0.015%, 0.03%, 0.06% [100-1006]
DeltaGard G (Deltamethrin) 0.1% [432-836]
Gentrol EC (Hydroprene) 0.06% [2724-351]
Generation Mini Blocks Bait (Difethialone) 0.0025% [7173-218]
Generation Blue Max Mini Block Bait (Difethialone) 0.0025% [7173-236]
Opti-Guard Ant Gel Bait (Thiamethoxam) 0.01% [10-1260]
Kicker EC (Pyrethrins) 0.05%, 0.1%, 0.2% [432-1145]
Kicker EC (Pyrethrins) 0.05%, 0.1%, 0.2% [432-1145]
LiquiTox II Bait (Disodium Salt of Diphocinone) 0.106% [12455-61]
Maxforce FC Ant Bait Stations (Fipronil) 0.01% [432-1256]
Maxforce FG Insect Bait (Hydramethrlnon) 1.0% [432-1262]
Maxforce Magnum Roach Gel Bait (Fipronil) 0.05% [432-1460]
Nylar EC (Pryiproxyfen) 0015%, 00.2% [11715-307-57076]
PT Cy-Kick Aerosol (Cyfluthrin) 0.1% [499-470]
PT Cy-Kick CS (Cyfluthrin) 0.0075%, 0.025%, 0.05%, 0.1% [499-304]
PT565 Plus XLO Aerosol (Pyrethrins) 0.5% [499-290]
PT Tridie Bulk Dust (Amorphous Silica) 40% (Pyrethrins) 1.0% [499-429]
PT Tridie Aerosol (Amorphous Silica) 8% (Prethrins) 0.6% [499-385]
Tempo Ultra WP (Cyfluthrin) 0.025%, 0.05% [432-1304]
Tempo SC Ultra (Cyfluthrin) 0.025%, 0.05% [432-1363]
ULD BP 100 ULV (Pyrethrins) 1.0% [499-452/11540-9]
ULD BP 300 ULV (Pyrethrins) 3.0% [499-450/11540-1]
Weatherblok XT Bait (Brodifacoum) 0.005% [100-1055]
Phantom SC (Chlorfenapyr) 0.5% [241-392]
Mother Earth Scatter Bait (Boric Acid) 5% [499-515]
Treatment Code
Please Select
3'Band
Balt
Crack & Crevices
Directed Contact
General
Inspection
Space
Spot
Void
Equipment Code
Please Select
Aerosol
Bait Gun
Bait Station
Comp. Air Sprayer
Hand Duster
Power Treatment
Spreader
Trap
ULV
Service Area
Area
Please Select
• Offices
• Public Areas
• Entryways
• Rest/Locker Rooms
• Janitor Closets
• Laundry
• Boiler Room
• Storage/Utility
• Warehouse
• Basement
• Patient Rooms
• ICU
• Linen Storage
• Kitchenettes
• Nurse Stations
• Guest Rooms
• Meeting Rooms
• Display Aisles
• Dining Area
• Stove/Oven Line
• Food Storeroom
• Dishwashing Area
• Deli/Bakery
• Processing Area
• Packaging Area
• Product Area
• Meat/Seafood Area
• Exterior Walls-North
• Exterior Walls-South
• Exterior Walls-East
• Exterior Walls-West
• Loading Dock
• Dumpster
• Exterior Storage Room
• Roof
Type of Pest
Please Select
American Cockroaches
Argentine Ants
Black Widow Spiders
Brown Recluse Spiders
Fire Ants
German Cockroaches
Hunting Spiders
Mice
Occasional Invaders
Oriental Cockroaches
Outdoor Cockroaches
Pavement Ants
Pharaoh Ants
Rats
Silverfish
Stored Product Pests
Web-Building Spiders
Specify Condition
Please Select
Drain Clogged/Dirty
Food Debris Under Table
Food Debris on Shelf
Food Debris Under Appliance
Wet Organic Matter in Cracks
Grease Deposits on Floor
Grease Deposits on Equipment
Soiled Dishes Left Over Night
Paper/Litter
Water Leak
Mops
Improperly Stored
Trash Containers Need Cleaning
Heavy Dust/Dirt Deposits
Numerous Cobwebs Present
Repair Floors/Tiles/Wall/Ceiling
Seal Holes/Cracks in Walls
Poor Storage Practices
Repair Water Damaged Wood
Seal Exterior Cracks/Holes
Trim Back Tree/Shrub Branches
Remove Piles of Debris
Cut Tall Grass/Weeds
Improve Outside Drain
Install Gravel Fountain Barrier
Move Dumpster Away from Bldg
Dumpster Area Needs Cleaned
Mercury Vapor Lights Outside
Keep Doors Closed
Repair Door/Screen
Replace Door Weather-Stipping
Poor Outdoor Storage Practices
Specify Used Materials
Glue Traps
Insect Monitors
Insiders
Liquid Baid Stations
Mouse Bait Stations
Pheromone Traps
Rat Bait Stations
Snap Traps
Tin Cats
Wind-Up Traps
Additional Notes
Customer Signature
Service Technician Signature
Submit
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