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STATE OF CALIFORNIA DEPARTMENT OF PESTICIDE REGULATION <br /> 1 PRIVATE APPLICATOR PESTICIDE ENFORCEMENT BRANCH <br /> CERTIFICATION STATEMENT <br /> PR-ENF-172(EST.7/91) CERTIFICATION EXPIRATION DATE <br /> 12- ' 3/ - 99r <br /> PRIVATE APPLICATOR NAME APPLICATOR PHONE NUMBER r/ <br /> �J M <br /> ADDRESS <br /> CER IFYING COUNTY NAME PERMIT NUMBER ISSUED COUNTY PHONE NUMBER <br /> 3q- - - <br /> CEATIFICATIOQPE R ISSU BY: t % TITLE <br /> CERTIFICATION ISSUED: <br /> fUGENERAL EXAMINATION WORKER SAFETY 6AMINATION <br /> 1 PESTICIDE SAFETY SERIES INFORMATION PROVIDED: PESTICIDE SAFETY SERIES INFORMATION[SERIES NUMBER(S)PROVIDED{: <br /> YES ❑ NO S'2Q rP <br /> I certify the above information is correct and that 1 have taken the Private Applicator Certification examination for the possession <br /> and/or use of restricted use pesticides. 1 have reviewed and understand questions answered incorrectly with the issuing county. <br /> CERTIFIED P�AIVAPPUICATOR SIGMA E + 4. DATE SIGNED/CERTIFIED <br /> /1719 <br /> Distribution: Cri inal my <br /> Canary—CertifiedPriva[eQppiicaCor Pink —Copy <br /> 6,Toch-7T-0 r7iq <br /> i <br /> i <br /> r <br />