Form PPQ 375 PPQ 375 Asian Longhorned Beetle Unified Survey

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UNITED STATES DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
PLANT PROTECTION AND QUARANTINE
AREA

ZONE NUMBER

ASIAN LONGHORNED BEETLE UNIFIED SURVEY

LEVEL (check one)
1

STREET

SURVEY DATA ENTERED
INITIAL
DATE

2

TOWN

ZIP CODE

TYPE OF SURVEY (check one)
First attempt
Call back
SURVEYOR AGENCY (check one)
APHIS/PPQ

SURVEYOR NAME(S)

House/
APT
Number

Inspection
Complete

Y

Contractor

PAGE
OF
U.S. Forest Service

DATE

B

S

INFEST

C

P

Neg/Pos

G

K

Inv/Sus

N

OMB APPROVED
0579-0311
EXP.: XX/XXXX

ACER Jap
(Maple) Acer

A

Y?

AESCULUS
(Horse
Chestnut)

BETULA SALIX ULMUS ALBIZZIA FRAXINUS
(Birch) (Willow) (Elm) (Mimosa)
(Ash)

H

B

S

U

Z

PLATANUS
(London
Plane)

F

L

POPULUS Cotton SORBUS KOELREUTERIA CERCIDIPHYLLUM
(Katsura)
(Poplar)
wood (Mt Ash)
(Goldenrain)

P

Y?

Mt

G

Kt

LOCATION
COMMENTS
DATE/TIME/INITIALS
B

F

C

SY

TOTAL
INSPECTION METHOD
B - Bucket truck
G - Ground survey

PPQ Form 375
FEB 2016

TREATMENT METHOD
C - Tree climb

S - Soil injection
D - Soil drench

INFEST
T - Trunk injection

N - Negative
P - Positive

TREE DESIGNATION
S - Suspicious
I - Inventoried

K - Park tree
S - Street tree

TREE LOCATION
P - Private tree

B – Back yard
C – Court yard

F - Front yard
SY - Side yard