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;TATE OF CALIFORNIADEPARTMENT OF PESTICIDE REGULATION <br /> 3RIVATE APPLICATOR In PESTICIDE ENFORCEMENT BRANCH <br /> CER T IF:CAT ON STAT EF&EN T <br /> i R-ENF-172(EST.7191) CERTIFICATION EXPIRATION DATE <br /> PRIVATE APPLICATOR NAME APPLICATOR PHONE NUMBE <br /> ��DDRESS <br /> 9L15-10 C 0 e 7,e <br /> ERTIFYING COUNTY NAME PERMIT NUMBER ISSUED COUNTY PHONE NUMBER <br /> p,­j 3 i L. ` lam- 94, $Z3 93 4,9- <br /> CERTIFICATION/PERMIT ISSUED BY: TITLE <br /> :ERTIFICATION ISSUED: <br /> !! GENERAL EXAMINATION :�4 WORKER SAFETY EXAMINATION <br /> FOESTICIDE SAFETY SEAIES INFORMATION PROVIDED: PESTICIDE SAFETY SERIES INFORMATION(SERIES NUMBERS)PROVIDED]: <br /> S NO <br /> i <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 PRIVATE APPLICATOR SfGNA E DATE SIGNEDICERTIFIED <br /> Distribution: Original—County Canary—Certified Private Applicator Pink —Copy <br /> STATE OF CALIFORNIA DEPARTMENT OF PESTICIDE REGULATION <br /> PRIVATE APPLICATOR PESTICIDE ENFORCEMENT BRANCH <br /> FCERTIFICATION STATEMENT <br /> PR-ENF-172(REV.12/94) <br /> CERTIFICATION EXPIRATION DATE d <br /> — 'Ido a1 <br /> PRIVATE APPL�AT R NAME APPLpICATOr�R PHONE NUMBER <br /> I <br /> ADDRESS d <br /> CERTIFYING COUNTY NAME PERMIT NUMBER ISSUED COUNTY PHONE NUMBER <br /> CERTIFICATIONIPERMIT ISSUED BY: TITLE <br /> CERTIFICATION TYPEIDATE ISSUED- <br /> ENERAL EXAMINATION ® WORKER SAFETY EXAMINATION ❑ ORAL EVALUATION <br /> DATE: DATE: DATE: <br /> FPESTICIDE SAFETY SERIES INFORMATION PROVIDED: PESTICIDE SAFETY SERIES INFORMATION(SERIES NUMBER(S)PROVIDED]: <br /> YES ❑ NO <br /> F1 certify the above information is correct and that I have taken the Private Applicator Certification examination for the possession <br /> 2 and/or use of restricted use pesticides. I have reviewed and understand questions answered incorrectly with the issuing county. <br /> CERTIFIED RIVA7- PI,ICATQA SI�NA E DATE SIGNED/CERTtFiED <br /> Distribution: Original—County Canary—Certified Private Applicator Pink —Copy I <br />