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Restricted Materials Perm: Conditions v./ Page#: 1 of 2 <br /> The Following Conditions Apply To . . . . . . . . . . . . . . . . . . . . . . Permit#: 39-04-3904929 <br /> -------------------------------------------------------- <br /> WORKERS SAFETY SERIES ATTACHED <br /> ------------------------------------------------------------------------------- <br /> [X] A-1 through A-9 General Info. [_] 9-1 Cholinesterase Testing <br /> PERMIT CONDITIONS ATTACHED <br /> ------------------------------------------------------------------------------- <br /> [X ] P - General <br /> [_] O - Dicamba & Phenoxy Herbicides - Central Valley/Hazardous Area <br /> [_] R - Dicamba & Phenoxys - Special Hazardous Area <br /> [_] S - Metam Sodium & Metam Potassium <br /> [_I T - Aldicarb (Temik ) <br /> [_I U - Endosulfan (Thiodan ) <br /> [_I V - Rice Pesticides Program <br /> C_] 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,B) <br /> [_] W - Methyl Bromide <br /> [_I Soil within greenhouses <br /> [_I Commodity <br /> C_] Soil injection <br /> [_] Tarped potting soil <br /> C_] Single tree site <br /> [_I X - Furadan chemigation of grapes <br /> [_J 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 /> [_I 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 C_] 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(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 /> there is no commissioner. <br /> - -------- ��------- ------------------ <br /> Purchaser Date <br />