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Nuv—Je— 004 11:51 CONDDR EARTH TECH 209 532 0773 P.03 <br /> SUPPLEMENTAL QUESTIONNAIRE FOR AGRICULTURAL SITES <br /> What is your relationship to the praperry? Owner- ❑ Occupant <br /> 1 <br /> ❑ Grower ❑ Other <br /> k <br />+ How long? <br /> Is the properry currently Used for any agricWturaI Yes No Unk <br />° use? <br /> What type of crop? <br /> Are there any pesticides currently being used on the Yes o Unk <br /> property? <br /> If yes,please list what types: <br /> Do you observe evidence or have any prior Yes No UUnk <br /> knowledge that pesticides were used on the <br /> propen y? <br /> Please Describe: <br /> Are any a cdjointngpropertfes being used for anYes No Unk <br /> 6 agricultural use? . <br /> If so,please indicate which ones: North South Bast West <br /> w What types? <br /> �►� 'L ] 0.i <br /> Are there any pesticides currently being used on any Yes No Un3c <br /> f. adjoining properties? <br /> If so,please indicate which ones: North South East West <br /> If yes,please list what types. — <br /> Do you observe evidence or have any prior Yes No Unk <br /> I knowledge that pesticides have been used on any . <br /> adjoining properries? <br /> If so,please indicate which ones: North South East West <br /> Please Desen'be: <br /> - Initials <br /> P <br /> E-M000_prj`A125K1 Wh Mupplemental Ag.doc' <br /> RECEIVED TIME NOV. 30. l i :51AM <br />