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SAN J0AQU IN NoRestricted Materials Permit— Supplement Application <br />Permit#:3905501 IT <br />--- operator: BLAGG FAMILY FARMS <br />Date: 3/25/2021 <br />SITE ID <br />LOCATION <br />TWN <br />RNG <br />SEC <br />DIRECTIVE <br />(Check Bax) <br />COMMODITY <br />ACRES/ <br />UNITS <br />PESTICIDES <br />3 <br />S <br />O <br />Z <br />3 <br />s <br />0 <br />PESTS <br />PCB/ <br />Grower <br />7 <br />Applied. <br />ADDCHANGE <br />REMOVE <br />1 8 <br />S1HW-12Vf,LoCUST-M= <br />03N <br />07E <br />03 <br />0 <br />GRAPE, WINE <br />2.5 <br />ON PERMIT <br />WEEDS <br />PCB/G <br />2. <br />3. <br />10001 <br />4. <br />—0() <br />S. <br />0 <br />n, <br />O <br />6. <br />O <br />011, <br />7. <br />8. <br />0 <br />9. <br />00 <br />O <br />10. <br />00 <br />'. <br />11. <br />O <br />12. <br />011 <br />13. <br />010 <br />' <br />14. <br />00 <br />15. <br />0.00 <br />`Formulation: <br />I L=Liquid B=Bait <br />i D=Dust F=Fumigant <br />1 G=Granule <br />W P=Wettable Powder <br />1O=Other <br />I"Method: A=Air <br />I <br />i F=Fumigation <br />t; �A G.c, rte,...: �Y �2 •-�I <br />Applicant: -r L�t--yt__ bI pts <br />Name <br />Issued By: a-,,. (1 � <br />Name <br />Signature <br />U <br />Ignat�Y�—" <br />Rev. 12/2020 <br />4�/-a ( <br />Date <br />Date <br />Page^ of <br />