720 final termite treatmentNew Construction Subterranean Termite
Service Record
This form is completed by the licensed Pest Control Comi
OMB Approval No. 2502-0525
(exp. 05/30/2018)
i-utinc reporting nuraen Tor tins collection oT intormation is estimated to average 15 minutes per response, including the time for reviewing Instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. This information
its required to obtain benefits. HUD may not collect this information, and you are not required to complete this form, unless it displays a currently valid OMB
control number.
Section 24 CFR 200.926d(b)(3) requires that the sites for HUD insured structures must be free of termite hazards. This information collection requires the
builder to certify that an authorized Pest Control company performed all required treatment for termites, and that the builder guarantees the treated area
against infestation for one year. Builders, pest control companies, mortgage lenders, homebuyers, and HUD as a record of treatment for specific homes will
use the information collected. The information is not considered confidential, therefore, no assurance of confidentiality is provided.
This report is submitted for informational purposes to the builder on proposed (new) construction cases when treatment for prevention of subterranean termite
infestation is specified by the builder, architect, or required by the lender, architect, FHA, or VA.
All contracts for services are between the Pest Control company and builder, unless stated otherwise.
Section 1: General Info rmation (Pest Control Company Information)
Company Name: Bugout
Company Address 530 3rd st N
Company Business License No. JB217600
FHANA Case No. (if any)
city Jacksonville Beach
State FL Zip 32250
Company Phone No. 904-743-8272
Section 2: Builder Info rmation
Company Name Viridian Builder Phone No. 904-626-9090
Section 3: Prope rty Information
Location of Structure (s) Treated (Street Address or Legal Description, City, State and Zip) 720 BONITA RD ATLANTIC BEACH, FL 32233
Section 4: Se rvice Into rmation
Date(s) of Service(s) 3/14/23 and 8/17/23
Type of Construction (More than one box may be checked) Q Slab E] Basement [:] Crawl [:] Other
Check all that apply:
® A. Soil Applied Liquid Termiticide
Brand Name of Termiticide: Premise Pre EPA Registration No. 432-1331
Approx. Dilution (%): •05 Approx. Total Gallons Mix Applied: 164 Treatment completed on exterior: 0 Yes E] No
B. Wood Applied Liquid Termiticide
❑❑❑❑ 0 00000 000000011000❑ 0000000 00000000❑❑❑❑
00 000 1100000 000 ❑❑ ❑❑❑ ❑ 000 000000
C. Bait system Installed
Name of System EPA Registration No _ _ _ Number of Stations installed
D. Physical Barrier System Installed
Name of System Attach installation information (required)
Service Agreement Available? ✓ Yes No
Note: Some state laws require service agreements to be issued. This form does not preempt state law.
Attachments (List)
Comments
Name of Applicator(s) Devan Houser
_ , Certification No. (if required by State law) JE265433
The applicator has used a product in accordance with the product label and state requirements. All materials and methods used comply with state and federal
regulations.
Authorized Signature _ Date 8-18-23
Warning: HUD will prosecute false claims and statements. Conviction may result in criminal and/or civil penalties. (18 U.S.C. 1001, 1010. 1012; 31 U.S.C. 3729, 3802)
form HUD-NPMA-99-B (08/2008)