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STATE OF CALIFORNIA DEPARTMENT OF PESTICIDE REGULATION <br /> PRIVATE APPLICATOR PESTICIDE ENFORCEMENT BRANCH <br /> Cl �IFICATION STATEMENT / 2 -,?/- 9 7 <br /> PR•ENF-172(EST.7191) CERTIFICATION EXPIRATION DATE <br /> 71 <br /> PRIVATE APPLICATOR NAME APPLICATOR PHONE NUMBER <br /> I 6 S U <br /> ADDRESS 3 <br /> I {'+r_`I \_ T — 1 ♦ (..�V <br /> S f <br /> CERTIFYING COUNTY NAME PERMIT NUMBER ISSUED COUNTY PHONE NUMBER <br /> CERTIFICATION/PERMIT ISSUED BY: A TITLE <br /> CERTIFICATION ISSUED: <br /> GENERAL EXAMINATION OVORKER SAFETY EXAMINATION <br /> PESTICIDE SAFETY SERIES INFORMATION PROVIDED: PESTICIDE SAFETY SERIES INFORMATION[SERIES NUMBER(S)PROVIDED]: <br /> YES NO <br /> I certify the above information is correct and that/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 SIGNATURE DATE SIGNED/CERTIFIED <br /> Distribution: Original—County Canary—Certlfied Private Applicator Pink —Copy <br />