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�1 Restricted Materials Permit— Supplement Application <br />�I <br />S A i �l :_'J 0 A Q U I! 3 Notes:AC1��/X� 6/�( t ,DCIf1Cl�{C �tXrmi>L �� Permit;*: &91!9_9617 <br />C \ T Y- Qtsoc�ac� S�f�Ls) <br />Operator: <br />l�r��h. Camuc� yu�ns rr✓�/ 3� Date: y�23/2G�r <br />SITE ID <br />,c <br />L. <br />LOCATION <br />C/Un 1 <br />TWN <br />RNG <br />SEC <br />DIRECTIVE <br />(Check Sox) <br />COMMODITY <br />ACRES/ <br />UNITS <br />011 <br />PESTICIDES <br />n <br />C <br />O <br />Z <br />o <br />O <br />PES4._� <br />un i <br />PCS/ <br />Grower <br />Applied? <br />ADD <br />:lIANGE <br />:E�1OV: <br />�II <br />3 <br />^. <br />O- <br />g. <br />O <br />10. <br />11. <br />13. <br />1?. <br />15. <br />I <br />*Formulation: <br />!=Ziqu;d B=301t <br />D=7USt F=Fuml am <br />G=Grcnu; e <br />w?=VlettaDle Powder <br />*`Method: A=Arr <br />F=FJ,7)iCa:iC^ <br />Jacob Samuel <br />Applicant: <br />Name <br />issued By� tIeK' i D <br />Name i <br />2-23-2021 <br />Date <br />Date <br />Page a I_ of <br />