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RESTRICTED MATERIALS PERMIT cont . Page 3 <br /> GILLIPS, <br /> RICHARD Q xmit * : 39-97-3901284 <br /> WORKERS SAFETY SERIES ATTACHED -- - <br /> F -----------r---------------------------------- -------------------------------- <br /> 'X] A-1 through A-9 General Info . ; [_] B-1 Cholinesterase Testing <br /> PERMIT CONDITIONS ATTACHED <br /> - -- <br /> --_-- ------------------------------------------------------------- <br /> r <br /> [X] Q - Dicamba & Phenoxy' Herbicides - Central Valley/Hazardous Area <br /> [_] R Dicamba & Phenoxys - Special Hazardous Area <br /> S - Metam Sodium (Vapam) - Sprinkler Irrigation Application <br /> [_] T - Aldicarb (Temik) <br /> [_] U - Endosulfan (Thiodan) <br /> V - Rice Pesticides Program <br /> 4 f_] 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 /> F[X] W - Methyl Bromide <br /> [_] Soil within greenhouses <br /> [_] Commodity <br /> F!" <br /> _ Soil injection <br /> [_] Tarped potting soil <br /> [_] Single tree site <br /> [_] X - Furadan chemigation of grapes <br /> F <br /> f-�-Z===Other--------------------------------====w_=_-=___--___-___-__--_______ <br /> PESTICIDE SALES : GROUNDWATER PROTECTION <br /> Fr>QThe 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: [J 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 /> the is no commissioner. <br /> Fil - -------- <br /> Purchaser Date. <br /> E_., <br /> FF, <br /> I <br />