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DEPARTMEN7OF❑FS7, DE <br /> STATE OF CALIFORNIA PESTICIDE ENFOACcMS•,-o,„•,;: <br /> PRIVATE APPLICATOR <br /> CERTIFICATION STATEMENT <br /> =R-ENF-172(EST.7191) CERTIFICATION EXPIRATION DATE <br /> Z—� —5 <br /> PRIVATE APPLICATOR NAME APPLICATOR PHONE NUMBER <br /> ADDRESS <br /> CERTIFYING COUNTY NAM PERMIT NUMBER ISSUED COUNTY PHONE NUMBER — <br /> !,. <br /> CERTIFICATION/"I IT ISSUED BY:ATITLE <br /> CERTIFICATION ISSUED: <br /> GENERAL EXAMINATION D_,VVORKER SAFETY EXAMINATION <br /> 7PESTICI SAFETY SERIES INFORMATION PROVIDED: PESTICIDE SAFETY SERIES INFORMATION(SERIES NUMBER(S)PROVIDED]: <br /> YES NO <br /> 1 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. f have reviewed and understand questions answered incorrectly with the issuing county. <br /> CER IFIEO PRIVAIE APPLICATOR SIGNATURE DATE SIGNED/CERTIFIEO <br /> Distribution: Original—County Canary—Certified Private Applicator Pink —Copy <br />