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RESTRICTED MATERIALS PERMIT cont . Page 4 <br /> COSTA INC . , DAN Permit : 39-96-3901016 <br /> ------------------ ----------- <br /> WORKERS SAFETY SERIES ATTACHED <br /> ------------------------------------------------------------------------------- <br /> [X] A-1 through A-9 General Info . [_] B-1 Cholinesterase Testing <br /> ---------------------------- <br /> PERMIT CONDITIONS ATTACHED <br /> ------------------------------------------------------------------------------- <br /> [XJ P - General <br /> [XJ 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 /> (_} 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: 0 , 8 ) <br /> [_] W - Methyl Bromide <br /> [_) Soil within greenhouses <br /> [?9. Commodity <br /> [_) Soil injection <br /> (_] Tarped potting soil <br /> (_] Single tree site <br /> [_] X - Furadan chemigation of grapes <br /> [_) Z - Other <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 /> [_} 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 [_J Bromacil <br /> [_} Diuron [_J 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 /> e no ioner. <br /> ------------------ <br /> Purchaser <br /> Date <br />