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S A =C=CAL��ORNIA <br /> PRIVATE APPLICATOR DEPARTMENT OF FOOD ANDAGRICULTU; <br /> PESTICIDE ENFORCEMENT BRAN, <br /> CERTIFICATION STATEMENT <br /> 33-172(EST.11/90) <br /> CERTIFICATION EXPIRATION DATE <br /> PRIVATE APPLICATOR NAME t Z 3 i —9 -j <br /> _ APPLICATOR P ONE NUMBER <br /> ADDRESS <br /> CERTIFYING COUNTY NAME PERMIT NUMBER ISSUED <br /> ` 1 COUNTY PHONE NUMBER <br /> S � <br /> 39-9H -39010_7 61 823-92c) <br /> CERTIFICATION/PERMIT ISSUED BY: TITLE <br /> CERTIFICATION I U D: <br /> GENERA XAMINATION WORKER SAFETY EXAMINATION <br /> PESTICIDE SAFETY SERIES INFORMATION PROVIDED: PESTICIDE SAFETY SERIES INFORMATION(SERIES NUMBERS)PROVIDED]: <br /> —I YES <br /> NO SeeerM t <br /> I certify the above information is correct and that l have taken the Private Applicator Certification examination for the possession <br /> and/or use of restricted use pesticides. l have reviewed and understand questions answered incorrectly with the issuing county. <br /> CERTIFIED PRIVATE APPLICATOR SIGNATUR� <br /> DATE SIGNEDICERTIFIED <br /> Distribution: Original—County Canary—Certified Private Applicator <br /> Pink --Copy <br />