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3 Page# : 1 of 3 <br /> x)84 Following Conditions Apply - - . . . . . . . . . . . . . . . . . . . Permit#: 39-03-3900084 <br /> WORKERS SAFETY SERIES ATTACHED <br /> A-1 through A-9 General Info- [_) B-1 Choiinasterase Tasting <br /> -----------------9 Gene----------------------------------------------------- <br /> r ------------ -------------------------------------------------------------- <br /> PERMIT CONDITIONS ATTACHED <br /> ---------------------------------------------------------------------------- <br /> L; } P - General <br /> ] Q - Dieamba & Phenoxy Herbicides - Central Valley/Hazardous Area <br /> ] R - Dicamba & Phenosyz - Special Hazardous Area <br /> ` ] S - Metam Sodium & Metam Potassium <br /> ] T - Aldicarb (Temik) <br /> ] U - Endosulfan (Thiodan) <br /> ] V - Rice Pesticides Program <br /> Molinate (Ordram) Worker Safety <br /> [_] Attachments 1-9: Molinate (1,6) thiobenearb (2,6,7) , carbofuran <br /> (3,6) , methylparathion (4..9) and malathion (voluntary: 5,81 <br /> W - Methyl Bromide <br /> [_} Soil within greenhouses <br /> [_] Commodity <br /> L. [_] Soil injection <br /> [_] Tarped potting soil . <br /> Singie tree site <br /> f ] X - uradan chemigation of gropes - <br /> �. ] Z - Other <br /> ------------ - - <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 /> The material I am purchasing will be used in a Pesticide Management Zone <br /> (as described in Section 6602, 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 [_} '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 <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 /> _yr_�_,_� ,a-a7-OL <br /> ------ - --------------- <br /> qWiurc haser Date <br />