Page 266 - AG 7-2011 Revised 2016

APPLICATION -RESTRICTED MATERIALS PERMIT PERMITTEE
PERMIT NO.
D FOR POSSESSION ONLY D FOR POSSESSION AND USE

PER MITTEE ADDRESS CITY ZIP PHONE TYPE OF PERMIT EXPIRATION

D PRIVATE APPLICATOR D STRUCTURAL PCO D AGRICULTURAL PCO D DSEASONAL JOB DATE ______________
D MUST BE SUBMITTED AT LEAST
NOTICE OF INTENT REQUIRED HOURS PRIOR TO APPLICATION. METHOD: D COMMERCIAL APPLICATOR
A. PESTICIDES/PESTS

1. 6. ------------------------ 11. -------------------------

2. 7. 12.

3. --------------------------- 8. ------------------------ 13.
4. 9. 14.

5. 10. 15.
B. LOCATION PESTS
1. MAP COMMODITY ACRESillNITS PESTICIDES F' M" RATE DILUTION/ APPL DATE/
SEC TWN RNG ID VOLUME TIME

2.

3.

4.

5.

6. ADDRESS PHONE PCO NAME ADDRESS PHONE
PCO NAME I

C JUSTIFICATION FOR NON-AG USE
D. CON DITIONS

I understand that this permit does not relieve me from liability for any damage to persons or property caused by the use of these pesticides. I waive any claim of 'FORMULATION: L--LIQUID B--BAIT D--DUST
liability or damages against the County Department of Agriculture based on the issuance of this permit. I further understand that this permit may be revoked when
F--FUMIGANT G--GRANULES
pesticides are used in conflict with the manufacturer's labeling or in violation of applicable laws, regulations, and specific conditions of this permit. I authorize
inspection at all reasonable times and whenever an emergency exists by the Department of Pesticide Regulation or the County Department of Agriculture of all WP--WETTABLE POWDER 0--0THER
areas treated or to be treated, storage facilities for pesticides or emptied containers and equipment used or to be used in used in the treatment. I have considered
"METHOD: A--AIR GR--GROUND
alternatives and mitigation measures pursuant to Tltle 3, California Code of Regulations, section 6426. Taking into account economic, environmental, social, and
technological factors, I have adopted those that are feasible and would substantially lessen any significant adverse impact on the environment. F--FUMIGATION 0--0THER

AP PLICANT__ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___ SIGNATURE _ _______________________ TITLE __ _ _ _ _ _ _ __ DATE-- - - - - �-

D RESTRICTED MATERIAL PERMIT IS HEREBY GRANTED FOR THE ABOVE MATERIALS. D APPLICATION DENIED BY _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _� DATE_ _ _ _ _ _ _ _�

DISTRIBUTION \M-llTE & YELLOWCOUNTY AGRICULTURAL CO MMISSIONER: PINK & GO LD-PER MITTEE STATE OF CALIFORNIA Print Form
DEPAR TMENT OF PESTICIDE REGULATION

PR-ENF-125 (REV. 11107) Page 1 of 1