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RESTRICTED MATERIALS PERM_ continued . . . . . Page# : 3 <br /> SCHALLBERGER, JOHN Permit# : 39-02-3904623 <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 /> [X] S - Metam Sodium ( Vapam) <br /> [_] T - Aldicarb (Temik) <br /> [X] 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 /> ------------------------------------------------------------------------------- <br /> PESTICIDE SALES : GROUNDWATER PROTECTION <br /> ------------------------------------------------------------------------------- <br /> - [J6 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 [_] 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 /> Purchaser Date <br />