Government of Ontario: Ministry of the Environment

Record of Land and Water Exterminations by an Airborne Machine

As required under Section 73(3)(a) and 85(3)(a) of  Regulation 63/09 made under the Pesticides Act. The licensed aerial exterminator is responsible for completing this document and the accuracy if it's contents. These records must be kept for two years following the date of pesticide application.






Property Owner



Telephone Number
Fax Number
Identification of Aircraft




Time of Extermination

       

1.
Time of Extermination - Left loading area full

   

Time of Extermination - Returned to loading area empty

   

Pesticide Used




Spray Pattern


Atmospheric Conditions




2.
Time of Extermination - Left loading area full

   

Time of Extermination - Returned to loading area empty

   

Pesticide Used




Spray Pattern


Atmospheric Conditions




3.
Time of Extermination - Left loading area full

   

Time of Extermination - Returned to loading area empty

   

Pesticide Used




Spray Pattern


Atmospheric Conditions




4.
Time of Extermination - Left loading area full

   

Time of Extermination - Returned to loading area empty

   

Pesticide Used




Spray Pattern


Atmospheric Conditions




5.
Time of Extermination - Left loading area full

   

Time of Extermination - Returned to loading area empty

   

Pesticide Used




Spray Pattern


Atmospheric Conditions




6.
Time of Extermination - Left loading area full

   

Time of Extermination - Returned to loading area empty

   

Pesticide Used




Spray Pattern


Atmospheric Conditions




7.
Time of Extermination - Left loading area full

   

Time of Extermination - Returned to loading area empty

   

Pesticide Used




Spray Pattern


Atmospheric Conditions




8.
Time of Extermination - Left loading area full

   

Time of Extermination - Returned to loading area empty

   

Pesticide Used




Spray Pattern


Atmospheric Conditions




*Location to be treated should match the location to be treated indicated in the permit issued.






Exterminator/Pilot



Record of incidents and comments