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F - Page#- 1 +.Df <br /> FP.estricted Maer,_a.�s Fermzi.: Condi�,i��ns Page#- <br /> C The Following Conditi-ors Apply To . . . . . . . . . . . . . . . . . . . . . . Permit#: 39-01-3904274 <br /> WORKERS SAFETY SERIES ATTACHED <br /> -----_- -------- -------- ------------- <br /> [X3 A-1 through A-9 General Info. C_3 &---1 Cholinesterase Testing <br /> u <br /> ------ PERMIT CONDITIONS ATTACHED <br /> ------------------------------------------------------------------------------- <br /> r t <br /> [X) P - General <br /> ' r' [_3 Q - Dicamba & Phenoxy Herbicides - Central Valley/Hazardous Area <br /> . i [_3 R - Dicamba & Phenoxys - Special Hazardous Area <br /> [_] S -- Metam Sodium & Metam Potassium <br /> # [_3 T - Aldicarb (Temik) <br /> # C_3 U - Endosulfan (Thiodan) <br /> V - Rice Pesticides Program <br /> [_3 Molinate (Ordram) Worker Safety <br /> C_3 Attachments 1-9: Molinate (1,6) thiobencarb (2,6,7 ) , carbofuran <br /> (3,6) , methylparathion (4,9) and malathion (voluntary: 6,8) <br /> W - Methyl Bromide <br /> F`} [_3 Soil within greenhouses <br /> [_3 Commodity <br /> I [_3 Soil injection <br /> �r [_3 Tarped potting soil <br /> [.-,3 Single tree site. <br /> F � [_3 X - Furadan chemigation of grapes <br /> [ 3 Z - Other <br /> PESTICIDE SALES:-�GROUNDWATER-PROTECTION <br /> ----- <br /> F--- -----------------------------------__---------- -----------__-----------_---- <br /> N <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 /> F . ulations) for agricultural, 'outdoor institutional or outdoor industrial <br /> _._ use. <br /> [_3 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 /> -f for agricultural, outdoor institutional or outdoor industrial use and a <br /> copy of any restricted materials permit is attached. <br /> Material purchased: [_3 Atrazine [_7 Simazine [_3 Bromacil <br /> [_3 Diuron [_] Prometon [_3 Bentazon <br /> II Certify under penalty of perjury that the foregoing statement is true, <br /> F 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 /> j there is no commissioner. <br /> o <br /> 1 � , <br /> a� ----- -------------- <br /> 1_ <br /> s / <br /> Date <br /> Purchaser <br />