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j ISTRICTED MATERIALS PERMIT cont. Page 4 <br /> BELLA VISTA FARMS Permit # : 39-98-3902017 <br /> --=---------------------------------------------------------------------------- <br /> ----------------------WORKERS SAFETY SERIES ATTACHED <br /> !e ----------------------------------------------------- <br /> [X] A-1 through A-9 General Info . ; [_] B-1 Cholinesterase Testing <br /> ------------------------------------------ - <br /> --------------------------------------- ----------------------------- <br /> ------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------- _ <br /> ------------------------PERMIT CONDITIONS ATTACHED <br /> ----------------------------------------------- <br /> [X] P - General <br /> XJ 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 /> 0 <br /> 7 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 /> (_J Soil within greenhouses <br /> [_] Commodity <br /> [_] Soil injection <br /> [_] Tarped potting soil <br /> (_] Single tree site <br /> 61_] X - Furadan chemigation of grapes <br /> [_] Z - Other <br /> V <br /> ----------------------------------------------------- <br /> PESTICIDE SALES : GROUNDWATER PROTECTION <br /> ------------------------------------------------------------------------------ <br /> 6(_] 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 /> L [_] Diuron [_] Prometon [_l 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 /> r there is no commissioner . <br /> ------------------ <br /> -------------------------- <br /> Purchaser Date <br />