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GF CM..._PES I 1 I rHodu�riA AGRICULTURE m6NTHJ PEST6DE SSE R60RT <br /> hl-ENF-0117C <br /> OF PESTICIDE REGULATION <br /> (REV.2/SB) <br /> Inst ctions: Sub it the wh9j c to the Agricultural Commissioner within 10 days of month following application. <br /> MO TH IV 1 YEAR 2 <br /> NURSERY 3 / <br /> Page(d <br /> OPERATOR ID/PERMIT NUMB4 A10, <br /> ER ��� OPERATOR(GRQN(ER� ) )�� R 98 CITY '� ZIP CODE <br /> 3 6 S' �e � f r�.E L;tix—N <br /> SITE IDE IFICATIONNUMBER TOTAL PLANTED ACREAGE/UNITS ICOUNTYVJMBER SECTION TOWNSHIP A� RANGE BASE A MERIDIAN <br /> B '^ 10 11 12 / 13 ©- /T' S 14 OfS 16 9 H <br /> COMMODI )ITE RTED C FIELD LOC/ATION / G1 <br /> 17 e��J 1B <br /> CHEMICAL DATMIME ACREAGENNRB APP. BLOCK IO EPA OR STATE REOHITRATION NUMBER TOTALPRODUCTUSED DAYS RATE DILUTION PRODUCT AND MANUFACTURER <br /> CODE NUMBER APPLICATION TREATED METHOD (N (FROM UBEO (CIRCLE ONE UNR REENTRY PERACRE <br /> COMPLETED (CHECK APPUCABLE) OF AEASUf�) <br /> 21 22 23 24 ONE) 25 26 Z7 28 29 30 31 <br /> AN 7 <br /> (/ 3 a OTHER❑ LS In PT OT GA <br /> OR ❑ <br /> MR ❑ <br /> OTHER❑ LB OZ PT OT GA <br /> OR ❑ <br /> NR ❑ <br /> OTHER❑ LB OZ PT OT GA <br /> OR ❑❑MR <br /> } q <br /> OTHER❑ LB OZ PT OT GA liAB , (1),K) <br /> OR <br /> MR <br /> OTHER 8 LB OZ PT OT GA JI <br /> OR <br /> NR <br /> OTHER[] LB OZ PT OT GAOR <br /> p <br /> MR <br /> OTHER❑ LS OZ PT OT GA ¢NI^W�A6�.�le9ti�l iF, QHU <br /> OR <br /> MR <br /> OTHER LB OZ PT OT GA <br /> MR <br /> AIR <br /> OTHER LB OZ PT OT GA <br /> OR <br /> MR "+� �'Ff, w <br /> OAR LB OZ PT OT GA I <br /> OR <br /> MR <br /> 8 /r <br /> OTHER❑ LB OZ PT OT GA <br /> MR <br /> OR <br /> OR <br /> LB OZ PT OT GA np''1� pw pip q y, r' <br /> MA <br /> NEn p is OZ Pr OT o!1 AGR. COMML - LS 1 ,ICK O <br /> 1-k OT1E L OZ PT OT GA <br /> REPORT PREPARED BY 1 DATE 5 REVIEWED BY <br /> Form Dietd wilon: White py--County Agricultural Commissiono , nk copy--DPR; Canary--Applicator, Goldenmd--Applicator FOR AGENCY USE ONLY <br />