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%lo.' N,/ <br /> SUPPLEMENTAL QUESTIONNAIRE FOR AGRICULTURAL SITES <br /> APN 173-210-07 <br /> What is your relationship to the property? <br /> Owner ❑ Occupant <br /> ❑ Grower ❑ Other <br /> V <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: <br /> V <br /> Do you observe evidence or have any prior Yes Co Unk <br /> ` knowledge that pesticides were used on the <br /> property? <br /> Please Describe: <br /> 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 /> 4 <br /> Are there any pesticides currently being used on any YesNo Unk <br /> adjoining properties? <br /> If so,please indicate which ones: North South East West <br /> If yes,please list what types: <br /> r. <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 ones: North South East West <br /> Please Describe: <br /> V <br /> Initials <br /> PA3916 East Main Street Development(Grupe)�3916 E Main Sheet Development Phase 1\Correspondence\Leuers\8upp. Ag. CL(- <br /> 07).doc <br />