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SifultSll.1L'L ruiLzA ni,o r.r.raiil conzinueu . . . . . Page#: 4 <br /> 6. BELLA VISTA FARMS Permit#: 39-01-3902017 <br /> ------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------- <br /> -----WORKERS-SAFETY SERIES ATTACHED <br /> --------------- ---------------------------- <br /> [X] A-1 through A-9 General Info. [_] B-1 Cholinesterase Testing <br /> ------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------- <br /> PERMIT CONDITIONS ATTACHED <br /> -------- ---------------------------------------=- <br /> ----------------------- <br /> CX] P - GGeneraeneral <br /> CX] Q - Dicamba & Phenoxy Herbicides - Central Valley/Hazardous Area <br /> [_] R - Dicamba & Phenoxys - Special Hazardous Area <br /> [_] S - Metam Sodium (Vapam) <br /> t_] T - Aldicarb (Temik) <br /> [_] U - Endosulfan (Thiodan) <br /> L V - Rice Pesticides Program <br /> [_] Molinate (Ordram) Worker Safety <br /> [_7 Attachments 1-9: Molinate ( 1, 6) thiobencarb (2,6,7) , carbofuran <br /> I (3,6) , methylparathion (4,9) and malathion (voluntary: 5,8) <br /> L W - Methyl Bromide <br /> [_] Soil within greenhouses <br /> [_] Commodity <br /> [_] Soil injection <br /> C_] Tarped potting soil <br /> 5[( Single tree site <br /> LC_] X - Furadan chemigation of grapes <br /> L_] Z - Other <br /> ------------------------------------------------------------------------------- <br /> - -- - - ----- <br /> _ <br /> PESTICIDE SALES: GROUNDWATER PROTECTION <br /> --------------------------------------------------------------- - <br /> L [_7 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 /> C_] 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: [_j Atrazine [_] Simazine [_] Bromacil <br /> [_] Diuron [_] Prometon C_] 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(x) in any <br /> ` <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 /> L <br /> L <br />