EOEEA-AGR

A. Property Owner and Location Information

Name of Requester(Required)

(Must have lawful control over the property)

First Last

Name of Property Owner

(If Tenant, you MUST complete Section C below)

First Last

Street Address(Required)

City or Town(Required)

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State

Zip(Required)

County(Required)

Email(Required)

Telephone(Required)

Cell Phone/Other

City/Town Parcel Identification Number

(ONLY required if no dwelling or street address)

B. Mailing Address (if different than above)

Street/P.O. Box

Address Line 1 Address Line 2 City State ZIP Code

C. If Tenant, you MUST provide Landlord name and contact information for your application to be considered complete.

Landlord Name

First Last

Landlords Address

Address Line 1 Address Line 2 City State ZIP Code

Landlords Email

Landlords Home Phone

Landlords Cell Phone/Other

D. Exclusion Request

Requesting exclusion from

Adulticide*

Larvicide* (only if area larvicide is applied is one acre or more)

*Adulticides are pesticides designed to control adult flying insects. Mosquito adulticide treatments are Ultra Low Volume (ULV) and are usually applied using truck based sprayers. These applications provide immediate short term relief from pestiferous mosquitoes and/or mosquitoes that carry disease.

*Larvicides prevent adult mosquito emergence by targeting mosquitos in their immature larval stage. Granular and liquid larvicides are usually applied by hand or aircraft directly to stagnant water containing these immature mosquitoes. The majority of District larvicide applications to wetlands in Massachusetts are made using naturally occurring bacteria such as Bacillus thuringiensis israelensis (Bti). Applications of larvicides can effectively reduce future area-wide adulticide applications.

Pursuant to 333 CMR 13.03(3), I understand that requests for exclusions or opt outs shall not be honored if:

The request is not made in accordance with 333 CMR 13.03;
The Commissioner of Public Health has certified that the application is to be made to protect the Public Health;
The Commissioner of the Department of Conservation and Recreation has certified that the application is necessary to contain an infestation of a recently introduced pest; or
The Commissioner of the Department of Agricultural Resources has certified that the application is necessary to contain an infestation of a pest which is a significant threat to agriculture.

Accept(Required)

I hereby certify under the penalties of perjury that the information submit is true and accurate and submitted for its intended purpose and that I am the property owner or lawful tenant and am authorized to submit this request under 333 CMR 13.03.