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APPLICATION-RESTRICTED MATERIALS PERMIT

PERMITTEE

FOR POSSESSION ONLY

FOR POSSESSION AND USE

PERMIT NO.

PERMITTEE ADDRESS

CITY

ZIP

PHONE

TYPE OF PERMIT

EXPIRATION

SEASONAL

JOB

DATE

PRIVATE APPLICATOR

NOTICE OF INTENT REQUIRED A. PESTICIDES/PESTS

STRUCTURAL PCO MUST BE SUBMITTED AT LEAST

AGRICULTURAL PCO HOURS PRIOR TO APPLICATION. METHOD:

COMMERCIAL APPLICATOR

1.

7.

13.

2.

8.

14.

3.

9.

15.

4.

10.

16.

5.

11.

17.

6.

12.

18.

B. LOCATION

SEC

TWN

RNG

MAP ID

COMMODITY

ACRES/ UNITS

PESTICIDES

PESTS

F*

M**

RATE

DILUTION/ VOLUME

APPL

DATE/ TIMING

1.

2.

3.

4.

5.

6.

7. PCO NAME

ADDRESS

PHONE

PCO NAME

ADDRESS

PHONE

  • C.

    JUSTIFICATION FOR NON-AG USE:

  • D.

    CONDITIONS:

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 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 pesticides are used in conflict with the manufacture'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 areas treated or to be treated, storage facilities for pesticides or emptied containers and equipment used or to be used In the treatment.

*FORMULATION: L--LIQUID B--BAIT D--DUST F--FUMIGANT G--GRANULES WP--WETTABLE POWDER O--OTHER

**METHOD:

A--AIR GR--GROUND F--FUMIGATION O--OTHER

PERMIT APPLICANT

SIGNATURE

TITLE

DATE

RESTRICTED MATERIAL PERMIT IS HEREBY GRANTED FOR THE ABOVE MATERIALS.

APPLICATION DENIED.

BY

DATE

DISTRIBUTION: WHITE & YELLOW-COUNTY; PINK & GOLD-PERMITTEE

ENFORCEMENT BRANCH

PR-ENF-125

(Rev. 9/00)

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