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�%w Id <br /> RESTRICTED MATERIALS PERMIT continued . . . . . Page#: 3 <br /> OLLERI VICTOR Permit# : 39-99-3900391 <br /> Ir_______________________ _________ <br /> - -------------------- - <br /> WORKERS SAFETY SERIES ATTACHED <br /> ----- --- -------------------------------- -------------- <br /> r [X] A-1 through A-9 General Info. [_] B-1 Cholinesterase Testing <br /> __________________ -- <br /> ---------------------------------------------------------------- <br /> PERMIT CONDITIONS ATTACHED <br /> --------------------------------------------- -------------------------------- -- <br /> [X] P - General <br /> 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 /> [X] 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 /> [_] W - Methyl Bromide <br /> 6. [_] Soil within greenhouses <br /> [_] Commodity <br /> [ ] Soil injection <br /> ` [_] Tarped potting soil <br /> [ ] Single tree site <br /> [_] X - Furadan chemigation of grapes <br /> [ ] Z - Other <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 /> [_] 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 /> [ J Diuron (_] Prometon [_] Bentazon <br /> 6' 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 /> V 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 /> ------------ -------- <br /> Purchaser Date <br />