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._.---- --- -__ _.--___-_ --- -------- -------- ------- <br /> C _ <br /> ' ' � __._ Customer informed Consent for Sporicidinm —�--_---- ___.,� <br /> � .,, / <br /> Customer Name: .1•hN(1(�t � `.( <c.'•,�_•O�(�1�C;F� � Date o1 Loss: _,jj.���i � <br /> — T-- �-- <br /> I.oss AJdress: _�,� i S� l��E'���11n c�Y� -' 1��1�P _ <br /> City: ��Lti�,C.'_` S?a[e: l:Jb Zip: ^��",`Qj L�— <br /> Thc undersigned dlent,Ldn6 the bullding owner,owners tepresentallve,or resldent,hereby acknowledqes Iha[Ihe P�avider idcnUOeJ bebw has <br /> provideJ him/hei�vith anovcrvie,v of lhe EPA�rcglstcrcd dlslnfedanl5podddin°DlslnfectanL � <br /> ClientundeislandsthatProviAer . <br /> • Appliesaidimi[rubla�pmdudsthatarerepisteredbylheUSEm�wnmen�alProtecUonAgency(t:PA)under5?ctlon3Reglstrationrequirements <br /> presaiLed 6y'lie Federal Insecticidc,Fungi;ide,xnd Rodcnllddc Act(fIFR��, ' <br /> • Applles;mlimlcrohlalp;oductslnacmrdancewlUmanufocWret'sproductloheldlrecUon:andlocal,;hte,andfedetalregutations. <br /> • Makesr.odaimsotapmducCselleqivenessotherthanlhosepermlttedbylheUS[PAonSporicldin•'eproductlabel. <br /> Client aulhu�ites Provldeno apply Sporicidin°Or,nd Yiuducts,i^mmerciallymanufactuied 6yCOF;TEC Ine./SpodclAin"Ulvlslon,a[thepruperly <br /> j IncatedatlheaddressaLrove. <br /> ProvlAer has InformeA Cllent of the following Ilmltaqons ol appl4h�e Sporlcldln°9rond Products et this property: <br /> . AdequatecomectwithmlcmorRanfsms.Uminµappllcalionolproducts,le:hniciansusequanlities.ndmethodsihatailotvphysicalcontaclof <br /> lhe solullon wilh contaminated materials and surlaz^s.Produds are not effecUve aGalnst microbes Ihe�du not uhYsically contacl. <br /> . Dlsinfectlnglsnotsterill:ation.Sporicidin•iseflectleeagalnstcerfainmicroor6�nl:m:LydislnfeUingnonporou;surlacesbu[doe:noi , <br /> sterllBe Ihe environment.lhe[rnironmen[al Prote<tion ARency In the DezUcides Glossary descrihes a d��slnlecla�t as'7t themlcal ihat des!roys <br /> vegetatheformsofharmful�nlcroorCanisms,buldoesnulordinod7ykillbaderialspme:"Oislnlec�ingdoesnulkillurinacNvateallgroupsar � <br /> formsclmlcroorganlzms. � � � <br /> � • IndaorEnvlroronenlalTeslln�.Onlyte�Unp6yaqualiliedlndoorenvirenmentalprotesslonalcandcterminethee(feclivenezso(Spodddln^ � <br /> � <br /> applicatinn In a 6uildln6�SpodUdln"disinfectant pwducls con[aln pho�maceutical active Ingwdicnls that ere EPA�reslslered to Inactivale <br /> ,� dlseasetaus�ng bacteria,vimsns,tuberwlosis,mold and nilldew.Still,for a:sessment ol bacleria conlaminaiion fevels,envlrumnental testing <br /> should be ron2ucted before a bWlding Is reocniplad.(Pmvider does nol otler indoor ertulronmenWl Msting seMce;.)W hlle Pwvlder follows <br /> mantAactmer's pioduct�utdellnes and n�oduct labcl infonnallnn�vhen applylnE Sp�rlcldin•,Provider wnnot verify the product's resutts <br /> aCalnst micraorganisms nhuuld Clicnt d=dine indoar tesling. <br /> • ReouurrenceoFCdntamhiatlai.0isinhclin{;anindnorenvlmnmentdorsnolguarantCethewntamiwtlonwillnotretum.0ioacrosols: <br /> Assessment and[nntrnl states lhat 6u ilding awners can help prevenl lulure mkrohlal contam!naqon by"avolding the«ndltlons Ihal led lo <br /> past mntamination"�page 15-4�.Shouid an infected pervi enter tha"deaned°room or have cun Wct with anolher 0�'i son,the <br /> mlcmorP.anlnms rould he Iransmitted ta Ihr.other perion or to a surlace. <br /> ProvlGnr hos Inlnrmed[ustomnr ol the foliowing chara:hNsUu ol the Spodcidlnm pmduA: <br /> • Appllcatlrn,Ttchnlciapsapplyprodur.tsincoinpintnacmrtlancewiNitheproductlaheling: � <br /> • Gpuricidln^�isinlectnnlshaveadisHnaodGithnlmaylinF�'��urafewdayslollmvingdeaning.5porlddln'anditsodnra;enonto�icanda�ill <br /> dlsslpale6raJuaily. • � . . <br /> . [hlotineblenchshnWAnotbnnnntlednAortoorfolleurhi�:Ihcann�icaNunulSuoricidin�0lslnfea[anls. <br /> . Por morc inlornation vislt lhc Cuntec,Inc wcb silc al�vrvivspnricidln.rnm. <br /> Ourservi�esareintendedtnadJressinlcmLlalronlaminalioninlhnareaswhr.rewodals6eli�CnerfmmedeustomernerresthatFroviderisnot f <br /> re;ponslMe(or mlrrohlal C,���'+�h and Mher comaminmin in othcr pai ts of ihe pw,erly,hidd�n�vllhin the sUucture or not dlsAosed Custnmer <br /> a�rees lo be hound 6y thc tenns anA mndlUons In lhe AuthorimHon ta Fcrform Sc�rka�Fncn(28UCV or 2&001)si6neJ by Clicnt. <br /> If any term of plovislon ul lhls 1larecmen�shall,in,ny�wlsdlUlun,he imalid or unenfoiccable,such lmm ur�:rorision shall hr.�ncllcrlivc as tn sud� <br /> jurisdiclion to Ihe eqent cl sud�irnalidiry•ur unenfnaeaLility without InvaliAatin�or renJ�dng unenfo�wable mch tenn m prm•islon In any other <br /> Juri;didionorlhcreimm�ingletmsandFroviswn;uflhlsaC«i�mnlohrrihanthaseastowhlrnitlshcldlm Ildo�nenfortttLlc. <br /> ��Custrnnc�'s5igmture;h(I�lR����'ll�k ;'f�iovidusSignature: �� L (��—�,_:-- ---- I <br /> � Printed Name� _..-l:1 L.l.L:�Cj--��'�l�-,b:?��J i�/-�Pranchise�lepal Name. .�...0 rj .�- ���t'. � �� � <br /> � / <br /> "`- �.. d/b/a tiEHVPRO°n(: ,`:..�L.X�I:_���� 1.�= i <br /> / �-F—. / <br /> I�Date: --L?��.J/.������—'1---�. . � .. Wlc: « r / ' � � <br /> / <br /> (�SERVPRO'INIFILffTUAL pROPEHTY,Inc. AlL pIGI1T5Rf5ERV[D fG0517071.0 ?�80 5/ll � <br /> Lnc1�Sf.Ri'I'NO°Flr:nd�UrttlrrdapniAnrtfr(hmcAandOpavrnl. - . �� <br /> �� <br />