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Restricted Materials Perk. Conditions Page#: 1 of '`° <br /> The Following Conditions Apply To . . . . . . . . . . . : . . . . . . . . . . PermitQ 39-03-3900096 <br /> --------------------------------------------------------------- <br /> --------- ------------------------------------------------- <br /> WORKERS SAFETY SERIES ATTACHED <br /> ------------------------------------------------------------------------------- <br /> [X] A-1 through A-9 General Info. ---_-[_]-B_1--Cholinesterase Testing <br /> PERMIT CONDITIONS ATTACHED <br /> L -------------------------------------------------------------------------------- <br /> [X] P - General <br /> [X] Q - Dicamba & Phenoxy Herbicides - Central Valley/Hazardous Area <br /> [_] R - Dicamba & Phenoxys - Special Hazardous Area <br /> [_] S -- Metam Sodium & Metam Potassium <br /> T - Aldicarb (Temik) <br /> (_] U - Endosulfan (Thiodan) <br /> [_] V - Rice Pesticides Program <br /> [_] Molinate (Ordram) Worker Safety <br /> [_] Attachments 1-9: Molinate (1 ,6) thiobencarb (2.6,7) , carbofuran <br /> (3, 6) , methylparathion (9,9) and malathion (voluntary: 5,$). <br /> [X] W - Methyl Bromide <br /> [_] Sail within greenhouses <br /> [_] Commodity <br /> (_] Soil injection <br /> [_1 TarPed potting soil <br /> 11I.Single tree site <br /> L (_] X - Furadan chemigation of grapes <br /> (_] Z - Other <br /> -------------------------------------------------- <br /> ------------------- <br /> PESTICIDE SALES: GROUNDWATER PROTECTION <br /> ------------------------------------------------------------------------------- <br /> L 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 f_] Simazine C_] Bromacil <br /> L [_] Diuron [_] Prometon [_] Bentazon <br /> I Certify under penalty of perjury that the foregoing statement is true, <br /> L and that I will not apply any material listed in Section 6800(a) in any <br /> 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 /> there is no commissioner. <br /> l--�-9_-0n_d <br /> Purchaser Date <br /> L <br />