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RESTRICTED MATERIALS PERF continued . . . . . Page# : 3 <br /> .. u <br /> SIERRA VISTA VINEYARD Permit#: 39-00-3904647 <br /> ------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------- <br /> WORKERS SAFETY SERIES ATTACHED <br /> ------------------------------------------------------------------------------- <br /> [X] A-1 through A-9 General Info. ; [_] B-1 Cholinesterase Testing <br /> ------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------- <br /> PERMIT CONDITIONS ATTACHED <br /> ------------------------------------------------------------------------------- <br /> [X] P - General <br /> [ 19 - Dicamba & Phenoxy Herbicides - Central Valley/Hazardous Area <br /> [_] R - Dicamba & Phenoxys - Special Hazardous Area <br /> [_] S - Metam Sodium (Vapam) <br /> [ I T - Aldicarb (Temik) <br /> [ I U - Endosulfan (Thiodan) <br /> [_] V - Rice Pesticides Program <br /> [I Molinate (Ordram) Worker Safety <br /> [-1 Attachments 1-9 : Molinate (1 ,6) thiobencarb (2,6 , 7) , carbofuran <br /> (3,6) , methylparathion (4,9) and malathion (voluntary: 5,8) <br /> [ I W - Methyl Bromide <br /> [_] Soil within greenhouses <br /> [_] Commodity <br /> [_] Soil injection <br /> [� Tarped potting soil <br /> [_] Single tree site <br /> [_] X - Furadan chemigation of grapes <br /> [ 1 Z - Other <br /> ------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------- <br /> --------------------------------- ------------ <br /> PESTICIDE SALES : GROUNDWATER PROTECTION <br /> _ ------------------------------------------------------------------------------- <br /> [�] The material I am purchasing will not be used in a Pesticide Management <br /> l Zone (as described in Section 6802 , Title 3, California Code of Reg- <br /> ulations) for agricultural , outdoor institutional or outdoor industrial <br /> use. <br /> [ I 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 [_] Simazine Bromacil <br /> [_] Diuron [_] Prometon C_] 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 /> PesLiD4L a Management Zone for agriculture, outdoor institutional or <br /> outdoorndustrial uses except in accordance with a permit issued by the <br /> _ county ricu al commissioner or the director in a county in which <br /> h re s commi si er . <br /> Purchaser Date <br />