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SUPPLEMENTAL QUESTIONNAIRE FOR AGRICULTURAL SITES <br /> MOUNTAIN HOUSE NEIGHBORHOOD, CA <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? ('m(t\ Qd_ -- <br /> Are there any pesticides currently being used on the Yes No Unk <br /> property? <br /> If yes, please list what types: C pp,y�,c�„Qp ,,fie n o�—� <br /> t T <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 /> C Are any adjoining properties being used for an Yes 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 LYe No n <br /> u4joining properrics' �— <br /> If so, please indicate which on North South East Wes <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 /> udjoining properties? <br /> If so, please indicate which on orthSouth East Wes <br /> Please Describe: <br /> Initials <br /> P:\Mountain House\IbnnsThase I Supplemental Ag.Questionnaire.doc <br />