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RESTRICTED MATERIALS PERT!- - cont . Page 3 <br /> 'v <br /> SHEA, H M Permit 0 ; 39-99-3902027 <br /> ------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------- <br /> WORKERS SAFETY SERIES ATTACHED <br /> ------------------------------------------------------------------------------- <br /> [X] A-1 through A-9 General Info. ; [_] B-1 Cholinesterase Testing <br /> ------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------- <br /> -------------------------------------------------- <br /> PERMIT CONDITIONS ATTACHED <br /> ------------------------------------------------------------------------------- <br /> [X] P - General <br /> [X] Q - Dicamba & Phenoxy Herbicides - Central Valley/Hazardous Area <br /> (_] R - Dicamba & Phenoxys - Special Hazardous Area <br /> [_] S - Metam Sodium (Vapam) <br /> [_] T - Aldicarb (Temik) <br /> (_J U - Endosulfan (Thiodan) <br /> [_] V - Rice Pesticides Program <br /> [_] Molinate (Ordram) Worker Safety <br /> [_] Attachments 1-9 : Molinate ( 1 , 6 ) thiobencarb (2 , 6, 7) , carbofuran <br /> ( 3 , 6 ) , methylparathion ( 4 , 9 ) and malathion (voluntary: . 5 , 8 ) <br /> [X] W - Methyl Bromide <br /> (_] Soil within greenhouses <br /> [_] Commodity <br /> (_] Soil injection <br /> (_] Tarped potting soil <br /> [_] Single tree site <br /> [_J X - Furadan chemigation of grapes <br /> [_J Z - Other <br /> ------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------- <br /> PESTICIDE SALES : GROUNDWATER PROTECTION <br /> ------------------------------------------------------------------------------- <br /> [_] 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 /> (_J 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 [_] Simazine [_] Bromacil <br /> [_] Diuron [_J Prometon (_] 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 />