Laserfiche WebLink
LT;e Folluwi g ,on,',it_,_._, e"' " • . . . . . . . . . . . . . . . • . - - . - Fere;._t#: 39 05 5901 w; <br /> ---------------------------------------------------------------------------------- <br /> WOR^ER,S SAFETY 1ERIES ATTAJ-,jFI:'- <br /> [X' A-i through A -9 General Info. -; B--1 Cholinesterase Testi-g <br /> PERMIT CONDITIONS ATTACHED <br /> F '--'--'-'---------------------------------- -- <br /> L [X] P - General <br /> [X] Q - Dicambag Phenoxy Herbicides - Central Valley/Hazardous Area <br /> [_] R - Dicamba & Phenoxys - Special Hazardous Area <br /> [_} S - Metarri Sodium & Metam Potassium <br /> [_] T - Aldicarb (Temik) <br /> [_] U - Endosulfan (Thiodan) <br /> I t_] V - Rice Pesticides Program <br /> [_] Molinate (Ordram) Worker Safety <br /> I_] Attachments 1-9: Molinate (1,6) thiobencarb (2,6,7 ) , carbofuran <br /> (3, 6) , methylparathion (4,9) and malathion (voluntary: 5,8) <br /> L [X1 W - Methyl Bromide <br /> [_] Soil within greenhouses <br /> [_] Commodity <br /> L [_] Soil injection <br /> [_] Tarped potting soil <br /> [_] Single tree site <br /> t_] X - Furadan chemigation of grapes <br /> C_] Z - Other <br /> ------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------- <br /> PESTICIDE SALES: GROUNDWATER PROTECTION <br /> --- ------------------------------------------------------------------------- <br /> [ I 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 6802, 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 C_] Simazine [_] Bromacil <br /> [_] Diuron C_] 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 /> j„ 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 /> 1 L there is no commissioner- <br /> Purchaser Date <br /> V <br />