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i <br /> Res't.rlcted Materials Permit Conditions � Page#: 1 of 3 <br /> The Following Conditions Apply To . . . . . . . . . . . . . . . . . . . . . . Permit#: 39-03-3900391 <br /> WORKERS SAFETY SERIES ATTACHED <br /> ------------------------------------------------------------------------------- <br /> L [X] A-1 through A-9 General Info. ; [_] B-1 Cholinesterase Testing <br /> ------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------- <br /> PERMIT CONDITIONS ATTACHED <br /> ----- --------------------------------------- <br /> [X] P - General <br /> L [X] Q Dicamba & Phenoxy Herbicides - Central Valley/Hazardous Area <br /> [_] R Dicamba & Phenoxys - Special Hazardous Area <br /> S Metam Sodium & Metam Potazsi.,an <br /> [_] T - Aldicarb (Temik) <br /> U - Endosul.fan (Thiodan,) <br /> [_] V - Rice Pesticides Prngram <br /> L [_] 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 /> L [_] Soil within greenhouses <br /> [_] Commodity <br /> [_] Soil injection <br /> ` [_] Tarped "potting sail <br /> [_] Single tree site <br /> [_7 X - Furadan chemigation of grapes <br /> i [_] Z - Other <br /> ------------------------------------------------------------------------------ <br /> PESTICIDE SALES: GROUNDWATER PROTECTION <br /> LroQI-The material I am purchasing will not be used in a Pesticide Management 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: [_3 Atrazine [_] Simazine [_] Bromacil <br /> [_] Diuron [_] 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 /> L 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 commissio er. <br /> J (J� <br /> Purchaser Date <br />