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RESTRICTED MATERIALS PERMIT cont . Page 4 <br /> 6BELLA VISTA FARMS Permit # : 39-99-3902017 <br /> ------------------- ------------------------------------------___=__ <br /> WORKERS SAFETY SERIES ATTACHED <br /> L-------------------------------------------------------------------------------- <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 /> LI_IJ R - Dicamba & Phenoxys - Special Hazardous Area <br /> S - Metam Sodium (Vapam) <br /> [_] T - Aldicarb (Temik) <br /> [_] U - Endosul£an (Thiodan) <br /> L [_J 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 /> (_7 Soil within greenhouses <br /> [_] Commodity <br /> [_J Soil injection <br /> (_] Tarped potting soil <br /> [_] Single tree site <br /> [_] X - Furadan chemigation of grapes <br /> [_] Z - Other <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 /> L Material purchased : [_] 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 /> 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 /> L there is no commissioner . <br /> -------------------------- ------------------ <br /> Purchaser Date <br /> L <br />