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RESTRICTED MATERIALS PERMIT continued . . . . . Paae* : 4 <br /> COSTA INC, DAN Permit# : 39-99-3901076 <br /> WORKERS SAFETY SERIES ATTACHED <br /> ------------------------------------------------------------------------------ <br /> [XJ A-1 through A-9 General Info . [ J B-1 Cholinesterase Testing <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 (Vapam) <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 ( 20 , 75 carbofuran <br /> ( 3 , 6 ) , methylparathion ( 1 , 9 ) and malathion ( voluntary: 5 , 8 ) <br /> [ ] W - Methyl Bromide <br /> [ ] Soil within greenhouses <br /> [ ] Commodity <br /> [ ] Soil injection <br /> [ ] Tarped potting soil <br /> [ ] Single tree site <br /> [ ] X - Furadan chemi^ation of grapes <br /> [ ] Z - Other <br /> ------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------ <br /> PESTICIDE SALES : GROUNDWATER PROTECTION <br /> ------------------------------------------------------------------------------- <br /> RIThe 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(x) in any <br /> Pesticide Management Zone for agriculture , outdoor institutional or <br /> tdoor industrial uses except in accordance with a permit issued by the <br /> 7N —coun grjoultural commissioner or the director in a county in which <br /> there i Comm* oner. <br /> rchaser Date <br />