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Aestricted Materials PerAT Conditions .... Page## : 1 of 3 <br /> The Following Conditions Apply To . . . . . . . . . . . . . . . . . . . . . . Permit# : 39-02-3900146 <br /> WORKERS SAFETY SERIES ATTACHED <br /> ------------------------------------------------------------------------------- <br /> [X] A-1 through A-9 General Info . [_] B-1 Cholinesterase Testing <br /> --------------------------------------------------------------------------------- <br /> -------------------------------------------------------------------------------- <br /> -------------------------------------------------------------------------------- <br /> -------------------------------------------------------------------------------- <br /> PERMIT CONDITIONS ATTACHED <br /> --------------------------------------------------------------------------------- <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 /> [_1 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 (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 /> [X] Z - Other <br /> ------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------- <br /> PESTICIDE SALES: GROUNDWATER PROTECTION <br /> -------------------------------------------------------------------------------- <br /> [_] 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 /> E_] The material I am purchasing will be used in a Pesticide Management Zone <br /> (as described in Section. 6602, 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 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 /> there is no commissioner. <br /> /- <br /> ------ ------ ----------- <br /> Purchaser Date Date <br />