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RESTRICTED MATERIALS PERMIT cont . Page 3 <br /> VAN DD FOL, JOIIN ,,,,Ormit 1 : 39-98-3903330 <br /> ---------------------- <br /> WORKERS SAFETY SERIES ATTACIIED <br /> ------------------------------------------------------------------------------- <br /> [X] A-1 through A-9 General Info. ; [_] B-1 Cholinesterase Testing <br /> PERMIT CONDITIONS ATTACIIED <br /> ------------------------------------------------------------------------------- <br /> [X] P - General <br /> [X] Q - Dicamba & Phenoxy IIerbicides - Central Valley/IIazardous Area <br /> [_] R - Dicamba & Phenoxys - Special Hazardous Area <br /> [_] S - Me-t-am Sodium (Vapam) <br /> [_] T - Aldicarb (Temik) <br /> [_] U - Er�dosulfan. (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 (4, 9 ) and malathion (voluntary: 5 ) 8 ) <br /> [X] 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 /> Other <br /> PESTICIDE SALES : GROUNDWATER PROTECTION <br /> ------------------------------------------------------------------------------- <br /> [v4,The material I am purchasing will not be used in a Pesticide Management <br /> Zone (as described in Section 6302 , 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 [_] Simazine [_] Bromacil <br /> [_] Diuron [_] Prometon [_] Bentazon <br /> I Certify under penalty of perjury that the foregoing stateruent is true , <br /> 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 /> coun Y1,agricultural commissioner or the director in a county in which <br /> th is n c - m' sioner. <br /> - <br /> - - ---------- ----f z ' - <br /> ----- <br /> Purchaser Date <br />