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-RESTRICTED 'MATERIALS PERiMIT continued . . . . . Pagek 3 <br /> SHEA, H M %.d Permit& 39-02-3902027 <br /> ------------------------------------------------------------------------------- <br /> WORnERS SAFETY SERIES ATTACHED <br /> ------------------------------------------------------------------------------- <br /> [X7 A-1 through A-9 General Info . ; [_] B-1 Cholinesterase Testing <br /> ------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------- <br /> PERMIT CONDITIONS ATTACHED <br /> ------------------------------------------------------------------------------- <br /> [;J P - General <br /> [liI CY - Dlcamba & Phenoxy Herbicides - Central Valley/Hazardous Area <br /> [_J R Dicamba & Phenoxys - Special Hazardous Area <br /> [_J S - Metam Sodium (Vapam) <br /> [_J T - Aldicarb (Temik) <br /> [_3 U - Endosuifan (Thiodan) <br /> [_J V - Rice Pesticides Program <br /> [_] Molinate (Ordram) Worker Safety <br /> [_J Attachments 1-9 : Molinate ( 1 , 6 ) thiobencarb ( 2, 6 , 7) , carbrfuran <br /> ( 3 , 6 ) , methylparathion ( 4 , 9 ) and malathion (voluntary: 5 , 8 ) <br /> [EJ W - Methyl Bromide <br /> [_J Soil within greenhouses <br /> [_J Commodity <br /> [_J Soil injection <br /> [_J Tarped potting soil <br /> [_] Single tree site <br /> [_] X - Furadan chemigation of grapes <br /> [_J Z - Other <br /> ------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------- <br /> PESTiCIDE SALES : GROUNDWATER PROTECTION <br /> ------------------------------------------------------------------------------- <br /> [_J The material I am purchasing will not be used in a Pesticide Management <br /> Zone (as described in Section 6802, Title 3 , California Code of Reg- <br /> ulations ) for agricultural , outdoor institutional or outdoor industrial <br /> use. <br /> [_] The material I am purchasing will be used in a Pesticide Management Zone. <br /> (as described in Section 6802 , Title 3 , California Code of Regulations) <br /> for agricultural , outdoor institutional or outdoor industrial use and a <br /> copy of my restricted materials permit is attached. <br /> Material purchased: [_] Atrazine [_1 Simazine [_J Bromacil <br /> [_J Diuron [_J Frometon [_J Bentazon <br /> I Certify under penalty of perjury that the foregoing statement is true, <br /> and that I will not apply any material listed in Section 6800(a) in any <br /> Pesticide Management Zone for agriculture , outdoor. institutional or <br /> outdoor industrial -uses except in accordance with a permit issued by the <br /> county agricultural commissioner or the director in a county in which <br /> there is no commissioner. <br /> -------------------------- ------------------ <br /> Purchaser Date <br />