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Page 3 <br /> RESTRICTED MATERIALS PERM' ,,,,cont . <br /> Permit # : 39-98-3802102 <br /> SURAT TOOK <br /> WORKERS SAFETY SERI E'S ATTACHED <br /> __ _ ------- <br /> --------------------- <br /> ---------_-- --------------~�_--B-1^-Cholinesterase Testing <br /> _JX] -A-1r_through-A_9_General-Info . <br /> _-_- _ -] ___ ______________..--___- ___-__ ____ <br /> ____PERMIT-CONDITIONS-ATTACHED <br /> ------ <br /> --------------------- <br /> - [g] p - General <br /> Herbicides '-cides - Central Valley/Hazardous Area <br /> [h] Q Diaamba & Phenoxy <br /> [r] R - Dicamba & Phenoxys - Special Hazardous. Area <br /> [_] S - Metam Sodium (Vapam) <br /> [_] T - Aldicarb (Temik) <br /> [_] U -' Endosulfan (Thiodan) <br /> [_] V - Rice Pesticides Program <br /> [_] Molinate (Ordram) Worker Safet. earbofuran <br /> [_] Attachments 1-9 : Molinate ( 1 , 6 ) thiobencarb ( 2 : 6 : 7 ) , 5 =8 ) <br /> (3 , 6 ) , methylparathion (4 , 9 ) and malathion {voluntary; <br /> [X] W - Methyl Bromide <br /> [_] Soil 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 /> __ __-_ -___________________________. __-_ �_____-_--_-_______-__-__ <br /> PESTICIDE SALES : GROUNDWATER PROTECTION <br /> ------------- <br /> ----- -material I am purchasing-will not -used-in-a-Pesticide Management <br /> [_] The <br /> Zone (as described in Section 6802 , Title 3 , California Code o Reg- <br /> Zone <br /> for agricultural, outdoor institutional or outdoor industrial <br /> use . will be used in a Pesticide Management Zone <br /> [J The material I am purchasing i <br /> (as described in Section 6i institutional orloutdoor industrial ifornia Code of guse tand sa <br /> for agricultural, outdoor ins <br /> copy of my restricted materials permit is attached. <br /> Material purchased: ] Atrazine [._] Simazine [_] Bromacil <br /> [_] Diuron [._] Prometon [_] 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 the <br /> outdoor industrial uses except in accordance with a permit <br /> r the director in a county in which <br /> county agricultural commissioner o <br /> there is no commissioner . <br /> �_________________________ Date <br /> Purchaser <br />