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San Joaquin County Agricultural Commissioner <br />Renewal Restricted Material Permit/OP ID Applicants Questionnaire* <br />RETURN THIS FORM TO: <br />Circle your District <br />Email: stocktonag2@sjgov.org <br />(if known) <br />Stockton Office: 2101 E Earhart Ave, Stockton, Ca, 95206 <br />A D I <br />Phone Number: (209)953-6000 Fax: (209)953-6022 <br />E F <br />Lodi Office: 10 W Locust Ave, Lodi, Ca, 95240 <br />C <br />Phone Number: (209)331-7287 Fax: (209)331-7288 <br />Simms Office: 17620 E HWY 120, Ripon, Ca, 95366 <br />Phone Number: (209)468-5542 Fax: (209)468-5544 <br />Dateo Requ t: <br />1 1q. <br />Business or Ranch Name: <br />, <br />Perm t Applicant's . irst and Last Na <br />Business Address: <br />Home Phone Number:Crff <br />,,,O) y�Z 7G7 Business: <br />Fax Number: <br />Email: <br />�cP� Udo `F pU,IJ <br />QAUQAC/PAC license holder: Name(s)? <br />License Number(s)? <br />Additional Contacts to be added to permit: <br />Do you have a pesticide dealer? If so, their name(s)? <br />Do you have a Pest Control Advisor (PCA)? If so, their name? <br />Do you have employees? 0 Yes LJ No If yes, are they: <br />Pesticide Handlers R9 Fieldworkers Neither <br />NOTICE: If you do not own a site that you intend to add to your permit you will be required to provide a letter of <br />authorization, lease agreement, or other documentation from the owner clearly stating that you are their authorized <br />representative in obtaining a Restricted Materials permit (RMP)/Operator Identification Number (Op Id) for that site as <br />defined in Section 6000 of the California Code of Regulations before that site can added to your RMP/Op Id. <br />Are there any changes to the permit? If so, what are they: (Use the back of this page if more space is needed) <br />20:-1 <br />IDO() 1V1 J'.Ni1C. i <br />Comments: <br />Applicant Signature: <br />"Excluding email addresses and telephone numbers, information on Restricted Material Permits and Operator Identification Numbers <br />is considered public record. <br />