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DEPARTMENT OF PESTICIDE REGULATION <br /> STATF OF CALIFORNIA PESTICIDE ENFORCEMENT BRANCH <br /> PRIVATE APPLICATOR <br /> CERTIFICATION STATEMENT <br /> PR-ENF-172(REV.12/94) E/ t,f CERTIFICA ON EXP RATION DATE <br /> V 1 :3! <br /> P IVATE APPLICATOR NAME : APPLICATOR PHONE N M13ER <br /> ADDRESS <br /> L7i ) AC r'` <br /> C RTIFYING COUNTY NAME PERMIT NUMBER ISSUED COUNTY PHONE NUMBER <br /> 7 - - <br /> CERTI ATIO /PERMIT ISSUED BY: TITLE <br /> /, R I v <br /> _ CERTIFICATION TYPE/DATE ISSUED: <br /> GENERAL EXAMINATION —WORKER SAFETY EXAMINATION ORAL EVALUATION <br /> DATE: - \' ' DATE: DATE: <br /> PESTICIDE SAFETY SERIES INFORMATION PROVIDED: PESTICIDE SAFETY SERIES INFORMATION(SERIES NUMBER(S)PROVIDED): <br /> YES NO <br /> 1 certify 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 /> CERTIFIED PRIVATE APPLICATOR S06NATURE DATE SI�G]NED/CERTIFIEEDD <br /> til <br /> Distribution: Original—CountyI Canary—Certified Private Applicator Pink —Copy <br /> 0 � <br />