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NOTICE OF THE USE OF PESTICIDES
UNDER BY-LAW 2007-0085 (Reg-1)


Town of Georgina-Leisure Services Department
26557 Civic Centre Road
Keswick, ON L4P 3G1
905 476 4301 or 705 437 2210

This notification is to be filed with the Town of Georgina at least three business days prior to application. A copy of the notification and supporting pictures is to be kept on file at the property for review if an inspection takes place. Inspection of the property is at the option of the Town.

Personal information on this form is collected under the authority of the Municipal Act and will be used for Municipal By-Law Enforcement purposes only. Questions about this collection should be directed to the Manager of Policy & Development, Town of Georgina,
905 476 4301 ext. 237.

REASON FOR APPLICATION (Please check one)
To control or destroy a health hazard

To control or destroy pests which have caused infestation to property


APPLICANT INFORMATION

First Name:

Last Name:

Street Number:

Street Name:

City:

Province:

Postal Code:

Telephone Number:

Email (Optional):



APPLICATOR INFORMATION

First Name:

Last Name:

Street Number:

Street Name:

City:

Province:

Postal Code:

Telephone Number:

Email (Optional):

Provincial Pesticides Operator License Number (Optional):



TYPE OF PESTICIDE

Name of Pest:

Name of chemical(s) being used:

Application method (eg liquid spray, pellet spreader, etc):

Approximate area to be treated:

Date Pesticide to be applied: