WPCv @(Y]Nq򦚃NhsԄN/턐/cb lYf<-/dE_Y3! @YфdX4kAE׎q+r]>THjAΏe4ҦJѓ)V") LРNiM|.X jb*yzEN1@V7wtnh ]*a$!@Ka6$/>K dc'<"-5|Z֔'S2YgoObDI|v}ZI&O2@5C9[kn] g!x:Z'0fБ*`MB档;M9JgpV\p v4K6CzsZm4AѮ1&.}昜= Ak\ߐ̨&f&Oc2z(b@PL3}\UeOe]wE#+#ZUN %i 0(ow4 mfaU*@5NK^ MMMMMMMMMMMMMMMMMMMMMMMMMM BYAcrobat Distiller0x9 Z6Times New Roman RegularX($LU+43|xU,TABLE A {&T Z(CG Times Regular X :5s  d !  _ XiXXX  X Xi/N@ VermontDepartmentofAgriculture,FoodandMarkets  Ѐ  R  ApplicationforaPermittoApplyPesticidestoaGolfCourse XiX R  XҀ B Ѐ DX XiRequestisherebymade,pursuanttoTitle6_V.S.A._ԀChapter87andtheregulations + Ѐpursuantthereto,forapprovaltoconductpesticideapplicationonagolfcourse.# XiX D#  X  RX Xi   R1.Generalinformation#  R  `# n  Ѐ XiX R DX Xia.GolfCourseName0  0@ (#(#򀀀~ @ (#@ (# # XiX D#󀀀 DX Xib.MailingAddress0  0@ (#(## XiX D#򀀀  @ (#@ (#  8   󀀀򀀀 k  󀀀 DX Xic.Location(ifdifferentfrom =  Ѐmailingaddress)0  0@ (#(#򀀀# XiX D#Ԁ&v @ (#@ (#  DX XiԀd.Manager/Superintendent @ 򀀀 H 󀀀Phone:򀀀   # XiX D# DX Xi󀀀e.NameandTitleofGolfCourse ; ЀOfficer0  0(#(## XiX D#򀀀L(#(#  DX XiԀf.DateofApplication0  򀀀(#(# # XiX D0 #  RX Xi   R2.PermitStatus#  R  E # x  XiX Ra.Initial򀀀    Renewal򀀀 󀀀Modification򀀀  b.Courseclassification:Existing򀀀  Existingw/proposedexpansion򀀀󀀀New/proposed򀀀 Z   RX Xi   R3.Pesticideinformation#  R   # ,| X XiX R DX XiA.Prescreenedpesticides:Listallpesticidesrequestedforusefromtheprescreenedlist# XiX D #: DX Xiattachadditionalsheetsasneeded. <  * * Xddd Xdd Xdd X%%, dd , dd , dd +  !6 !6   EPA_Reg.No_.  J"!  ActiveIngredient  J""  ProductName J"#      V#$   V#%  V#&      b$'   b$(  b$)      n% *   n% +  n% ,      z&!-   z&!.  z&!/      '"0   '"1  '"2      (#3   (#4  (#5      )$6   )$7  )$8      *%9   *%:  *%;      +'<   +'=  +'>      ,(?   ,(@  ,(A      -)B   -)C  -)D      .**E   .**F  .**G      /6+H   /6+I /6+J   _   D3.b XiX  Nonprescreenedpesticides:Listallpesticidesnotontheprescreenedlistbeingrequestedforuse. 0+J /N X   Additionalinformationmustbeprovided.Seeinstructions. X   X Xi4.GolfCourseDescription( XiX  seeinstructionsfordetails) * ̀a.SitePlan # Ѐb.Topographicmap(USGStoposheetpreferred).   Ѐc.Greens/Teessizesinsquarefeet.Identifyallwithin100feetofsurfacewater.  Ѐd.FairwayAcreageseparatecloselymowedandroughareas  Ѐe.Drainageareaofsurfacewaters  o Ѐf.Surfaceacreageanddepthofpondedsurfacewatersandlocationofsupplysource  X  Ѐg.Soilsmapandkey  A    X Xi5.Pesticidemanagementplan( XiX  seeinstructionsfordetails) k   ̀a.Generalpolicy/GoalStatement d  Ѐb.Descriptionofpestproblems M  Ѐc.Pestmanagementpracticesused 6 Ѐd.Pestmonitoringmethods  Ѐe.Pesticidestorageandhandlingprocedures  Ѐf.Irrigationpractices  Ѐg.Uniquefeaturesdesignedtominimizepests  Ѐh.Pesticideapplicationbufferzones k   X Xi6.Permitprovisions = ̀ XiX  a.Theundersignedacceptsfullresponsibilityforcomplyingwithallprovisionsandconditionssetforthin ] Ѐthepermitandforcomplyingwithallrequirementssetforthin6V.S.A.Chapter87andtheregulations m Pursuantthereto. V ̀b.Theundersignedfurtherunderstandsthatannualpesticideapplicationrecordsmustbemaintainedfor5 ( Ѐyears.TheserecordsshallbemadeavailabletotheCommissioneruponrequest. i ̀c.theundersignedfurtherunderstandsthatanyauthorizationforpesticideuseislimitedtothepesticides, ;   Ѐpracticesandlocationsspecifiedintheapprovedpermit. $!!   RX XiDated򀀀0 0 % %0H%%򀀀#!$H%H% 0 8 08%8%0%%0@ %%0 @ %@ %0 % %0H%%0H%H%Superintendent%"%%%  8      @     H 򀀀 u'%' 󀀀0 8 08%8%0%%0@ %%0 @ %@ %0 % %0H%%0H%H%GolfCourseOfficer