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APPLICATION - RESTRICTED MATERIALS PERMIT - SUPPLEMENT PERMIT NO. <br />PAGE NO. <br />LOCATION <br />SEC <br />TWN <br />RNG <br />MAP <br />ID <br />COMMODITY <br />ACRES/ <br />UNITS <br />PESTICIDES <br />PESTS <br />F` <br />M— <br />RATE <br />DILUTION/ <br />VOLUME <br />APPL <br />DATE/ <br />TIMING <br />J <br />9. <br />Ajf <br />10. <br />11. <br />12. <br />13. <br />14. <br />- <br />15. <br />16. <br />17. <br />18. <br />19. <br />20. <br />21. <br />22. <br />23. <br />24. <br />25. <br />26. <br />27. <br />28. <br />29. <br />30. <br />31. <br />'Formulation: L—Liquid B—Bait D—Dust F—Fumigant G—Granules <br />WP—Wettable Powder 0-0ther <br />—Method: A—Air F—Fumigation Gr—Ground O—Other <br />DISTRIBUTION: COUNTY AGRICULTURAL COMMISSIONER; PERMITTEE <br />( <br />APPLICANT SIGNATURE DATEI, j I <br />ISSUED,. ^"�-"��'.--�=" J✓ __ <br />DATE <br />STATE OF CALIFORNIA <br />DEPARTMENT OF PESTICIDE REGULATION Print Form �� <br />PR-ENF-125A (REV. 10/07) Page 1 of 1 <br />