Structural Pest Control Business / Qualifying Manager Registration Form

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RIVERSIDE COUNTY AGRICULTURAL COMMISSIONER
STRUCTURAL PEST CONTROL BUSINESS / QUALIFYING MANAGER REGISTRATION
BRANCH 2 & 3
Date Submitted: _________________
For Year: 2016
COMPANY INFORMATION:
Performing work in:
Branch 2 &/or
Branch 3
Company Name: __________________________________ PR License No. ________________
Mailing Address: _________________________________________________________________
______________________________________________ Zip: _____________
Telephone: (
) ____________ Fax: (
) _____________ Email: ______________________
Physical Address: _________________________________________________________________
(if different than above)
______________________________________________
Zip: _____________
OPR:
Lic:____________ Exp: ________ Branch 2 / Branch 3
(Print Name)
SUPERVISION:
Qualifying Manager – QM; Branch Supervisor – BS (Responsible Person)
QM:
Lic:____________ Exp: ________ Branch 2 / Branch 3
(Print Name)
BS: __________________________________ Lic:____________ Exp: ________ Branch 2 / Branch 3
(Print Name)
REGISTRATION INFORMATION / FEES:
(Submit all pages with appropriate fees, and signatures)
Total Fees Submitted: __________
Make check payable to: County of Riverside
Print Name: __________________________________ Date: ______________________
Signature: ____________________________________ Title: _______________________
I certify that the information provided is TRUE and CORRECT
Agricultural Commissioner’s Signature _________________________________ Date: ______________
THIS REGISTRATION WILL NOT BE VALID IF IT IS NOT ACCOMPANIED BY THE REQUIRED FEE
(if applicable). Food and Agricultural Code section 15204(a) requires each licensed Branch 2 and Branch 3 structural pest control
operator qualifying manager and (SPCB) registered company to register with the commissioner prior to operating a structural
pest control business in the county. The registration shall cover a calendar year. A fee may also be required at the time of registration.
The fee shall be set by the county Board of Supervisors, except that in no case shall the fee exceed the actual cost of processing
the registration or ten dollars ($10), whichever is less. Registrations may be amended to add or change operator qualifying manager
and/or branch location(s) during the year for a fee not to exceed ten dollars ($10).
Est. 11/2007
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