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SUPPLEMENTAL QUESTIONNAIRE FOR AGRICULTURAL SITES <br /> MOUNTAIN HOUSE NEIGHBORHOODS <br /> What is your relationship to the property? ❑ Owner ❑ Occupant <br /> ❑ Grower Other <br /> How long? <br /> Is the property currently used for any agricultural Yes No Unk <br /> use? <br /> R . <br /> What type of crop? "4 <br /> Are there any pesticides currently being used on the Yes No Unk <br /> property? <br /> If yes,please list what types: S—" J-1;J <br /> Do you observe evidence or have any prior Yes No Unk <br /> knowledge that pesticides were used on the <br /> property? <br /> Please Describe: <br /> Are any adjoining properties being used for an res No Unk <br /> agricultural use? <br /> If so,please indicate which ones: North South East West <br /> What types? <br /> Are there any pesticides currently being used on any Yes No Unk <br /> adjoining properties? —^ <br /> If so,please indicate whi ones: North South East <br /> If yes,please list what types: <br /> Do you observe evidence or have any priorYes No Unk <br /> knowledge that pesticides have been used on any <br /> adjoining properties? --- <br /> If so,please indicate which on North South East West <br /> Please Describe: <br /> } Initials I Li— <br /> PAMountain House\2496\Supplemental Ag.Checklist.doc <br />