Syracuse University
Environmental Health Office

Notification of Pesticide Application

Send to Environmental Health Office (EHO) 72 hours prior to activity!
fax: 443-3081 phone:443-9133

Reminder - If you need to cancel or modification this application notification following its submittal, please complete the Pesticide Application Cancellation/Modification form and submit to EHO .

---

From:
    Department:
  Today's Date:
  Pesticide Applicator:
      Date of Activity:
                  Pest:                    
             Pesticide:                  
   Label/MSDS on file?: Yes No (click for choices)
 Method of Application:
        Exact Location:
      Time of Activity:am pm (click for choices)

---