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iTE, j STIC cSULAI --- _ _ _ ._._ _. ._ ..._.. - -- <br /> _ <br /> MGI,Le. ;vee) F` ' i r r r r r r i 1 a r 1 1 r t r <br /> Instruct;on'+s�: Suub-mit the white cop eto the Agricultural Commissioner within 10 days of month following application. <br /> MOM Al ' YEAR Z <br /> NURSERY 3 <br /> Page_of <br /> OPERATOR ID/PERMIT NUMBER OPERATOR(G OW ER) ADDRESS ,, _ CITY F. ZI CODE <br /> 15 e�C 3: B 5405 <br /> SITE IDENTIFICATI N NUMBER TDTAL PLANTED ACREAGE/UNITS ICOUNTYNUMB§R SECTION TOWNSHIP NGE ASE&MERIDIAN <br /> N E <br /> B w 10 11 12 13 14 15 S M H <br /> COMMODITY/SITE TREATED FIELD LOCATIOONN <br /> CHEMICAL D TE/TI ACAEAGEIUNNS APP. BLOCK IO EPA OR STAT E REGISTRATION NUMBER TOTAL PRODUCT USED DAVE RATE DILUTION PRODUCT AND MANUFACTURER <br /> CODE NUMBER APPLICATION TREATED METHOD (IF (FROM LABEL) (CIMEONEUNR REENTRY PERACRE <br /> COMPIETEO (CHECK APPLICABLE) OF MEASURE) <br /> 21 22 23 24 ONE) 25 26//� V 28 29 30 31 <br /> ofMR <br /> % DRIER❑ T 1 I " �J LB OZ P7 OT OA O <br /> an ❑ <br /> AIR ❑ <br /> OTHER❑ LB OZ PT OT GA <br /> OR ❑ <br /> MR ❑ <br /> OTHER❑ LB OZ PT OT GA <br /> OR ❑ <br /> MR <br /> OTHER LB OZ PT OT GA <br /> OR ❑ <br /> AIR <br /> OTHER LB OZ PT OT GA <br /> OR ❑ <br /> AIR ❑ <br /> OTHER ❑ LB OZ PT OT GA <br /> an ❑ <br /> MR ❑ <br /> OTHER❑ LB OZ PT OT GA - <br /> OR ❑ <br /> AIR p <br /> OTHER❑ LB OZ PT OT GA <br /> OR ❑ <br /> MR p❑ <br /> OTHER❑ LB OZ PT OT GA - <br /> OR ❑ <br /> AIR ❑ <br /> OTHER❑ LB OZ PT OT GA <br /> uA a v <br /> OTHER❑ LB oz Pr or GA fEn <br /> OR SMR <br /> OmER❑ LB OZ PT OT GA CIG <br /> DR <br /> AIR <br /> OTHER❑ L13 OZ PT OT GA <br /> \/ mHERn�❑ LB OZ PT OT GA <br /> REPORT PREPARED BY '1 ��G r P G 1 (0.1 y�� (k", V T- ' DATE 9 REVIEWED BY <br /> Form Distribution: White copy--County Agricultural Commissioner; P c copy--DPR; Cane <br /> ry--Applicato ; Golde rod--A plicator FOR AGENCY USE ONLY <br />