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DEPA RTME NT OF PESTICIDE REGULATION <br /> NATE OF CALIFORNIA I� PES'iCIDE ENFORCEMENT BRANCH <br /> PRIVATE APPLICATOR <br /> CERTIFICATION STATEMENT <br /> �R-ENF-172(EST.7191) I� CERTIFICATION EXPIRATION DATE <br /> 1 II APPLICATOR PHONE NUMBER <br /> �IRIVATE APPLICATOR NAME �^ <br /> ADDRESS _ <br /> [EATIFYING COUNTY NAMEP ERM IT NUMBER ISSUED COUNTY PHONE NUM BER <br /> IS f3Y: TIT T4(ERTIPICATION/PERMIT <br /> ERTIFICATION ISSU <br /> GENERAL E INATION F .WORKER SAFETY EXAMINATION 'I <br /> ff .L i! <br /> E' PESTICIDE SAFETY SERIES INFORMATION PROVIDED: PESTICIDE SAFETY SERIES INFORMATION[SERIES NUMBER(SI PROVIDED]: <br /> YES NO <br /> I certify the above information is correct and that 1 have taken the Private Applicator Certification examination for the possession <br /> indlor use of restricted use pesticides. I have reviewed and understand questions answered incorrectly with'the issuing county. <br /> i <br /> ERTIFIED PRIVATE PLICATOR SIGNATURE iE I DATE SIGNEWCERTIFIED <br /> � <br /> L <br /> istribution: Original—County Canary—Cerrtiiied Private Applicator Pink —Copy <br /> N � I <br /> ATE OF CALIFORNIA I DEPARTMENT OF PESTICIDE REGULATION <br /> V PESTICIDE ENFORCEMENT BRANCH <br /> RIVATE APPLICATOR <br /> ^ERTIFICATION STATEMENT II <br /> I-ENF-172(EST.7191) I <br /> CERTiFICATIONIEXPIRATION DATE <br /> IIVATE APPLICATOR NAME I APPLICATOR PHONE NUMBER <br /> ADDRESS <br /> CA. <br /> I <br /> [TTIWING COUNTY NAME PERMIT NUMBER ISSUED COUNTY PHONE NUMBER <br /> CERTIFICATION/PERMIT TIT <br /> Vr I <br /> '! LRTIFICA-nUE ; <br /> GENERAL EXAMINATION -1WORKER SAFETY EXAMINATION � I� M <br /> PESTICIDE SAFETY SERIES INFORMATION PROVIDED: PESTICIDE SAFETY SERIES INFORMATION]SERIES NUMBER(S)PROVIDED]: <br /> iI-: YES El NO 7 <br /> I 'k <br /> edify the above information is correct and that I have taken the Private Applicator Certification examination for the possession <br /> " and/or use of restricted use pesticides. I have reviewed and understand questions answered incorrectly with the issuing county. <br /> �RTIFIED PRIVATE APPLICATOR SIGNATURE ' DATE SIGNEWCERTIFI I <br /> { Y <br /> Cana Certified Private Applicator Pink —Copy <br /> Etribufion: Original—County ry— li pP <br /> I <br />