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. -- __- <br />/| [he Foliowing Conditions Apply To ~^=.=.=.=.=.=.=.=.=.=.=.=.=.=.=.=. <br /> =P=e=r=w==it=#==:=3=9=-=0 <br /> =6=-=3=9=0 <br /> =4=1=0 <br /> =0 <br /> = <br /> WORKERS SAFETY SERIES ATTACHED . <br /> ----------------------------------------------------------------------------- <br /> � �X] A-1 through A-9 General Info. | [_] B-1 Cholinesterase Testing======= <br /> - PERMIT CONDITIONS ATTACHED <br />. ----------_-------------_-----------------_----------_-----_----------_---- <br /> P - General <br /> Q - Dicamba & Phenoxy Herbicides - Central Valley/Hazardous Area <br /> _] R - Dicamba & Phenoxys - Special Hazardous Area <br />� ] S - Metam Sodium & Metam Potassium <br />' [_] T - Aldicarb (Temik) <br />' [_] U - Endosulfan (Thiodan) <br /> _] <br /> V <br /> R[ic]e Pesticides Program <br /> F4 M linate (U dram) W <br /> orker Safety <br /> hi b b (2 6 7) carbofuran <br /> Attachments1 9 �olivate ( 1 6) t o encar r ` , <br /> [_] - : , ,^ , , `� _ . ' _� <br /> ,6) , me^hylparathion (459) and malathion (voluntary: 5,8) <br /> � [_] W - Methyl Bromide <br /> � ^ [_] Sail within greenhouses <br /> [_] Commodity <br /> [_] 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 /> WJ <br /> ulations) for agricultural, tdoor institutional or outdoor industrial <br /> outdoor <br /> | <br /> use. will be used in a Pesticide Management Zone <br /> � A . [_] The material I am purchasing62w Titl 3 California Code of Reg«latim»s) <br /> (as described io Section u0 , e , ' <br /> 0-3r agricultural , outdoor institutional or outdoor industrial use and a <br /> | copy of my restricted materials permit is attached. <br /> FIJI, <br /> . <br /> Materia} purchased: [_] Atrazine [_] Simazine [_] Bromacil <br /> [_] P too [_] Bentazon <br /> [_] Diuron rome <br /> F, Q] <br /> Certify under penalty of perjury that the foregoing statement is true, <br /> ~ and that I will not apply any material listed in Section 68000> 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 /> ' i the director in a county in which <br /> county agricultural <br /> commissioner or <br /> "there is no commissioner. <br /> /~2 <br /> -01-7:---- ------- ------------------- <br /> Date <br /> ----------------- <br /> Date <br /> ( <br /> Fi <br /> Fit\ <br /> ` <br /> | <br /> F'. <br /> , <br />