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STATE OF CALIFORNIA DEPARTMENT OF PESTICIDE REGULATION <br /> CIV ATE APPLICATOR PESTICIDE ENFORCEMENT BRANCH <br /> RTIFICATION STATEMENT <br /> PR-ENF.172(EST.7/91) <br /> CERTIFICATION EXPIRATION DATE <br /> P IRATE APDL�j{�ATOR E APPLICATOR PHONE NUMBER <br /> t h +i Rat,-, 1' 4' <br /> A06RESS <br /> y <br /> CERRFYINGCOUNTYNAmF PERMIT NUMBER ISSUED COUNTY PHONE NUMBER <br /> CERTIF ERMTT 193UED BY: c/7 , <br /> CERTIFICATION ISSUED: <br /> Q GENERAL EXAMINATION F] WORKER SAFETY EXAMINATION <br /> PESTICIDE SAFETY SERIES INFORMATION PROVIDED: PESTICIOE SAFETYSERIES INFORMATION(SERIES NUMBER(S)PROVIDED): <br /> z YES E] NO <br /> I certify the above information is correct and that I hav taken the Private Applicator Certification examination for the possession <br /> andior use of restricted use pesticides. I have rev-1 rstand ques ions answered incorrectly with the issuing county. <br /> CERTIFIED PRIVATE APPUCATOR SIGNATU DATE SIGNED/CERTtFIED <br /> Ile <br /> [�'-3+ution: Original—County r -"' Canary—Certified Private Applicator Pink Copy <br />