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STATE OF CALIFORNIA DEPARTMENT OF PESTICIDE REGULATION <br /> PRIVATE APPLICATOR PESTICIDE ENFORCEMENT BRANCH <br /> CERTIFICATION STATEMENT <br /> PR•ENF-172(EST.7/91) CERTIFICATION EXPIRATION DATE <br /> PRIVATE APPLICATOR NAME - N APPLICATOR PHONE NUMBER <br /> ADDRESS <br /> CERTIFYING COUNTY NAME -` PERM u NUMBER ISSUED I COUNTY PHONE NUMBER <br /> CERTIFICATION/PERMIT ISSU D BY: TITLE <br /> 61 <br /> 2E57FICATION ISSUED: <br /> GENERAL EXAMINATION 2r WORKER SAFETY EXAMINATION <br /> PESTICI AFIETY SERIES INFORMATION PROVIDED: PESTICIDE SAFETY SERIES INFORMATION(SERIES NUMBER(S)PROVIDED]: <br /> YES E NO <br /> I certify the above information is correct and That I have taken the Private Applicator Certification examination for the possession <br /> a �seestricted use pesticides. I have reviewed and understand questions answered incorrectly with the issuing county. <br /> C TI IVATE APP R SIGNATUR DATE SIGNED/CERTIFIED <br /> Distribution: n Canary—Certified Private Applicator Pink —Copy <br />