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STATE OF CALIFORNIA <br /> DEPARTMENT OF PESTICIDE REGULATION <br /> CQIVATE APPLICATOR PESTICIDE ENFORCEMENT BRANICH <br /> _RTIFICATION STATEMENT <br /> PR-ENF-172(EST.]AI) <br /> CERTIFICATION EXPIRATION DATE <br /> T- n \ <br /> PRIVATE APPLICATOR NAME APPLICATOR PHONE NUMS 0!7BER <br /> s — s - ob <br /> ADDRESS <br /> S <br /> CERTIFYING COUNTY NAME PERMR NUMBER ISSUED COUNTY PHONE NUMBER <br /> CERTIFICATIOWPERMIT ISSUED BY: TITLE` <br /> S. 1 Q j <br /> CE (CATION <br /> GENERAL EXAMINATION EXAMINATION 0/ORKER SAFETY EXAMINATION <br /> PESTICIDE SAFETY SERIES PIFORMATION PROVIDED: PESTICIDE SAFETY SERIES INFORMATION[SERIES NUMBERS)PROVIDEDJ: <br /> YES E] NO <br /> NO <br /> I 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 SIGNATURE DATE SIGNEDICERTIFIED <br /> D i <br /> Distribution: Original—County Canary—Certified Private Applicator Pink —Copy <br /> `/ �v-e.L-y <br />