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',TATE OF CALIFORNIA DEPARTMENT OF PESTICIDE REGULATION <br /> PRIVATE APPLICATOR PESTICIDE ENFORCEMENT BRANCH <br /> CERTIFICATION STATEMENT <br /> 'R-ENF-172(EST.7141) CERTIFICATION EXPIRATION DATE <br /> PRIVATE APPLICATOR NAME APPLICATOR PHONE NUMBER/ <br /> NDDRESS <br /> i <br /> :E G COUNTY PERMIT NUMBER ISSUED COUNTY PHONE NUMBER <br /> I <br /> :ER7iFICATION/PERMiT ISSUED BY: TITLE <br /> CEFITIFICATION ISSUED: <br /> GENERAL EXAMINAT19Z OWORKER SAFETY EXAMINATION <br /> PESTICIDE SAFETY SERIES INFORMATION PROVIDED: PESTICIDE SAFETY SERIES INFORMATION[SERIES NUMBER(S)PROVIDED]: !1 <br /> YES NO J <br /> - I <br /> '!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. t have reviewed and understand questions answered incorrectly with the issuing county. <br /> CERTIFIEDPRIV APPLICATOR RE DATE SIGNED/CERTIFIED <br /> Distribution: Origin — unty Canary—Cerdfied Private Applicator Pink —Copy <br /> I <br /> i` <br /> I <br /> i <br />