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RESYITICTED MATERIALS PERMIT continued . . . . . Page# : 3 <br /> VKN DE POL, JOHN Permit# : 39-00-3903339 <br /> ------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------- <br /> WORKERS SAFETY SERIES ATTACHED <br /> ------------------------------------------------------------------------------- <br /> [li] A-1 tliroiigli A-9 General Info . [_] B-1 Cholinesterase Testing <br /> ------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------- <br /> PERMIT CONDITIONS ATTACHED <br /> ------------------------------------------------------------------------------- <br /> [-'%,'] P - General <br /> [Y] Q - Dicamba & Piienoxy Herbicides - Central Valley/Hazardous Area <br /> [_] R - Dicamba. & Plieiioxys - Special Hazardous Area <br /> S - Metaim Sodium (V apam) <br /> [_] T - Kldi6arb (Temik) <br /> [_] U - Endosulfan (Thiodan' <br /> ` [_J V - Rice Pesticides Program <br /> [_] Moliiiate (Ordram) Worker Safety <br /> [_] Attachments 1-9 : Molinate ( 1 , G ) tniobencarb {2 , G , i ) , carbofuran <br /> ( 3 , G ) , methylparathion ( 4 ,9 ) and walathion (voluntary: 5 , ) <br /> 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 /> [_] Z - Other <br /> PESTICIDE SALES: GROU1141DWATER PROTECTION <br /> ------------------------------------------------------------------------------- <br /> r, + 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 /> Lr_'J T}ie material I aim purchasing will be used in a Pesticide Management Zone <br /> as described iii Section 6802 , Title 3 , California Code of Regulations ) <br /> for agricultural , outdoor institutional or outdoor industrial use and a <br /> .m copy of illy i'esitic leu iliaieriaia Yertt►iir 'L--i ai.i.auiicu. <br /> Material purcliased: [_] Atrazine [_] Siimaziiie [_] Broriacil <br /> too [_] Diuron [_] Prometoti [_] Beiitazon <br /> I Certify under penalty of perjury that the foregoing statement 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 /> county agricultural commissioner or the director in a county in which <br /> the e A s n" c mm u' tier. <br /> �- -- --------- <br /> Purchaser Late <br />