Pest Control Treatment Certificate

• Site conducted

  Select

• Company Name

  Qube Energy

  Chevron

• Property Address

  42 Ulm Place, Hazelmere

  NWSB

  Other

• Date

  Date

• Technician Name

  Allan Polkinghorne

  Mark Byleveld

  Other

• Job Number

Treatments and Areas Serviced

• Type of Treatment

  Select Container Treatment Residual Spray Rodents Snail Pellets Spiders Flying Insects Escargo Yard Equipment Fogging ULV Weeds Fumigation Crawling Insects Other

  • Container Treatment
  • Residual Spray
  • Rodents
  • Snail Pellets
  • Spiders
  • Flying Insects
  • Escargo
  • Yard Equipment
  • Fogging
  • ULV
  • Weeds
  • Fumigation
  • Crawling Insects
  • Other

Treatment And Release Information

• Asset Number

Treatment Information

• Type of Chemical Used

  Select Ethyl Formate Suspend Flexx Pestigas Rodent Bait Suspend Flexx, Pestigas & Ditrac Profume Country Glyphosate 360 Biflex Aquamax Insecticide Ditrac Talon Garrards Pyrethrin Drift Aqua K

  • Ethyl Formate
  • Suspend Flexx
  • Pestigas
  • Rodent Bait
  • Suspend Flexx, Pestigas & Ditrac
  • Profume
  • Country Glyphosate 360
  • Biflex Aquamax Insecticide
  • Ditrac
  • Talon
  • Garrards Pyrethrin Drift
  • Aqua K

Fumigation Treatment Certificate Doc No: SHSMS-QE-14-FM-PSB-0002 Revision No: 001 Date: 17/12/2021

Ethyl Formate Usage

• Site - 42 Ulm Place, Hazelmere, WA, 6055

• Brand Name: Sigma - Aldrich

• Active Components: Ethyl Formate (EF) @ 90g / m3 in Nitrogen

• Equipment: EF Vaporiser Trolley and Nitrogen Generator

Fumigation Information

• Amount of Ethyl Formate Used

  2 Litres

  3 Litres

  4 Litres

  5 Litres

  6 Litres

• Gassing Time / Date

  Date

• Venting Time / Date

  Date

• Zero PPM reading achieved

• Additional Comments

Fumigator Release

• Fumigator Name

  Morgan Leaf

  Nicole Wojtczak

  Mik Niechciol

• Fumigator Signature

  Sign

• Other People Present

  Select Morgan Leaf Nicole Wojtczak Mik Niechciol

  • Morgan Leaf
  • Nicole Wojtczak
  • Mik Niechciol

Pestigas

• Is Company Quarantine Approval Required?

  Yes

  No

  N/A

• Has approval been sought by Company Quarantine in this instance?

  Yes

  No

  N/A

• Contact details of Company Quarantine Personnel responsible for approval

• Gassing Date

  Date

• Venting Location

  Onsite

  DSB

  Offsite

• Venting Date

  Date

• "Venting" must be selected in "Carry Over Work"

• Company Quarantine Approval must be sought prior to proceeding with the use of this chemical in this instance

• Has approval been sought by Company Quarantine in this instance?

  Yes

  No

  N/A

• Contact details of Company Quarantine Personnel responsible for approval

• Gassing Date

  Date

• Venting Location

  Onsite

  DSB

  Offsite

• Venting Date

  Date

• "Venting" must be selected in "Carry Over Work"

• Gassing Date

  Date

• Venting Location

  Onsite

  DSB

  Offsite

• Venting Date

  Date

• "Venting" must be selected in "Carry Over Work"

Rodent Bait

Suspend Flexx, Pestigas & Rodent Bait

• Venting Location

  Onsite

  DSB

  Offsite

• Venting Date

  Date

• "Venting" must be selected in "Carry Over Work"

Profume

• Is Company Quarantine Approval Required?

  Yes

  No

  N/A

• Has approval been sought by Company Quarantine in this instance?

  Yes

  No

  N/A

• Contact details of Company Quarantine Personnel responsible for approval

• Gassing Date

  Date

• Venting Location

  Onsite

  DSB

  Offsite

• Venting Date

  Date

• "Venting" must be selected in "Carry Over Work"

• Venting Date

  Date

• Company Quarantine Approval must be sought prior to proceeding with the use of this chemical in this instance

• Has approval been sought by Company Quarantine in this instance?

  Yes

  No

  N/A

• Contact details of Company Quarantine Personnel responsible for approval

• Gassing Date

  Date

• Venting Location

  Onsite

  DSB

  Offsite

• Venting Date

  Date

• "Venting" must be selected in "Carry Over Work"

• Gassing Date

  Date

• Venting Location

  Onsite

  DSB

  Offsite

• Venting Date

  Date

• "Venting" must be selected in "Carry Over Work"

• Biflex Aquamax Insecticide

Completed

• Residual date

  Date

• Additional Comments

Pest Technician Release

Technician Release Signoff

• Date

  Date

• Pest Technician

  Select Allan Polkinghorne Mark Byleveld Other

  • Allan Polkinghorne
  • Mark Byleveld
  • Other

• Pest Technician

• Qube Energy

• License Number

• Allan Polkinghorne

  Sign

• Pest Technician

• Qube Energy

• License Number

• Signature

  Sign

• Pest Technician

• Qube Energy

• License Number

• Mark Byleveld

  Sign