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T= "tel �O u�T1(Am iaGkti.tJLTurct <br /> Mum ' 'r-E5' DE"U,E RtPORI- <br /> DEPARTMENT OF PESTICIDE REGULATION <br /> PR-ENF-017C(REV.2199) <br /> Instructions: Submit the white copy to the Agricultural Commissioner within 10 days of month following application. <br /> t <br /> VON V 1 YEAR 2 <br /> NURSERY 3 Page-Of <br /> OPERATOORR ID/PERMIT NUMBER '] OPERATOR(GROWER) ADDRESS n(7 CITY [/ ZIP COOS <br /> 4 3 l -o - CA V� 5 6 C� c Uz 1� 7 -t J 8 �- <br /> SITE IDENTIFICATION NUMBER TOTAL PAfN/TI/W ACREAGE/UNIT COUNTY NUMBER SECTION TOWNSHIP RANGE BASE& iDIAN <br /> 9 10 ` 0 11 �} 12 13 S 14 I ry 15 S FE <br /> COMMODITYISITJ ( j� <br /> ETTTRREA�TED FIELD LOCATION <br /> I� <br /> 17 <br /> CHEMICAL DATEfTiME ACREAGE1UNITS APP- BLOCK ID EPA OR STATE REGISTRATION NUMBER TOTAL PRODUCT USED DAYS RATE PER DILUTION PRODUCT AND MANUFACTURER <br /> CODE NUMBER APPLICATION TRLATE METHOD (IF (FROM LAUEL) (CIRCLE ONE UNIT REENTRY ACRE <br /> COMPLETED ICHECK APPLICABLE) OF MEASURE) <br /> 21 22 23 24 ONE} 25 26 27 28 29 30 31 <br /> GR <br /> OTHER E] Z �',Po LB OZ PT GA TA y` <br /> GR r� <br /> AIR ❑ <br /> OTHER ❑ D�'sv�' B DZ PT E� GA L <br /> ! �d OTHER C] �'[ 73 <br /> AIR n ,�L�t_.rst "' Z/ 1 LB OZ�7 PT GA �� <br /> GR [�Q <br /> O AIR V <br /> Z � OTHER ❑ 1— s ` ���` LB OZ PT QT GA { <br /> �C AIR E:] < <Ef' r 3OC� <br /> aL� OTHER ❑ OZ PT QT GA (� <br /> ZL� <br /> AIR lr (( -3 (l <br /> GR <br /> OTHER ❑ /O��Z^ PT QT GA 1 <br /> GR ❑ t 1(l OZ V <br /> 7 AIR <br /> OTHER ❑ L DZ PT QT GA <br /> R 700 <br /> AIR l` S <br /> U GOTHER ❑ L' ^OZZ�,',',�PTT��"}QT GA <br /> AR L"{ Z Z 0 OITHER ❑ t i a/ j B OZ PT OT GA t <br /> -,7C) GR AIR [t 3 0 D i -C <br /> O HER E] U� LB OZ PT QT GA e' •.r'°..';i:: ;1 \ r_, a})) <br /> GR ❑ yy ) 3 �� sty x .n I: 'i t. <br /> AIR ❑ 1E' '; <br /> OTHER ❑ LB OZ PT QT GAGR El <br /> AIR ❑ <br /> OTHER{] LB OZ PT OT GA <br /> n <br /> GR <br /> AIR 11vc ii I(! <br /> OTHER ❑ LB OZ PT QT GA A4 '�"` <br /> OR <br /> Y5. ?G.�i. t— <br /> AIR <br /> CHER LB OZ PT OT GA <br /> REPORT PREPARED BY DATE ra REVIEWED BY <br /> F rm Distribution: WhIte copy County Agricultural Commissioner; Plnk copy DPR; Canary--Applicator; Goldenrod Applicator FOR AGENCY USE ONLY <br />