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SUPPLEMENTAL QUESTIONNAIRE FOR AGRICULTURAL STIES <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 /> What type of crop? <br /> Are there any pesticides currently being used on the Yes No Unk <br /> property? <br /> If yes,please list what types: eQ �t'r. <br /> Do you observe evidence or have any priorYes No Unk <br /> knowledge that pesticides were used on the <br /> property? <br /> Please Describe: <br /> CAre any adjoining properties being used for an Yes No Unk <br /> agricultural use? �..-- <br /> if so,please indicate which onesl� South East s� <br /> What types? <br /> Are there any pesticides currently being used on any Ye No Unk <br /> adjoining properties? _ <br /> If so,please indicate which ones--North South East W� <br /> If yes, please list what types: ------------ <br /> Do you observe evidence or have any prior Yes No Unk <br /> knowledge that pesticides have been used on any <br /> adjoining properties? �� _ <br /> If so,please indicate which es: North orth South East Wes <br /> Please Describe: <br /> Initials <br /> P Wountain House\2496'Supplementel A&Checldist.doc <br />