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FORM A <br />RICE PESTICIDES WATER MANAGEMENT REQUIREMENTS, <br />Emergency Release Request Form <br />Thiobencarb <br />Grower:- <br />Address:- <br />Field <br />rower:Address:Field Location: <br />Chemical applied:_ <br />Rate of application:— <br />Date of application:_ <br />Average water depth <br />at time of application: <br />Permit No.: <br />Site No.: <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: 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 />Applications by: <br />Date: <br />Grower's signature: <br />Approved by: <br />Agricultural Biologist <br />(Rev. 1-10) <br />D-8 <br />