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FORM A <br />RICE PESTICIDES WATER MANAGEMENT REQUIREMENTS, <br />Emergency Release Request Form <br />Thiobencarb <br />Grower: Permit No.: <br />Address: <br />Field Location: <br />Chemical applied: <br />Rate of application: <br />Date of application: <br />Average water depth <br />at time of application: <br />Starting date of emergency release: <br />Acres treated in field: _ <br />1p: <br />ite No.: <br />Chemical applied: <br />Rate of application: <br />Date of application: <br />Average water depth <br />at time of application: <br />Laser leveled: Yes No <br />Type of irrigation system: Flow through Recycle Static Other <br />Date flooding began: No. of days it takes to fill field: <br />Describe problem that led to emergency release: <br />Steps that can be taken to prevent emergency releases from this field in future years: <br />Recommendation by (attached): <br />Annlinntinnc hv- _ <br />--rr----- ----- I <br />Grower's signature: Date: <br />Approved by: <br />Agricultural Biologist <br />(Rev. 1-10) D-8 <br />