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S ATE OF CALIFORNIA DEPARTMENT OF PESTICIDE REGULATION <br /> PRIVATE APPLICATOR PESTICIDE ENFORCEMENT BRANCH <br /> CERTIFICATION STATEMENT <br /> PR-ENF-172(EST.7/91) <br /> CERTIFICATION EXPIRATION DATE <br /> PRIVATE APPLICATOR NAME APPLICATOR PHONE NUMBER <br /> f f ( I� <br /> ADDRESS <br /> 7 <br /> CERTIFYING COUNTY NAME PERMIT NUMBER ISSUED COUNTY PHONE NUMBER <br /> y6 , <br /> CERTIFICATION/PERMIT ISSUED BY: TITLE <br /> CERTIFICATION ISSUED: <br /> GENERAL EXAMINATION WORKER SAFETY EXAMINATION <br /> PESTICIDE SAFETY SERIES INFORMATION PROVIDED: PESTICIDE SAFETY SERIES INFORMATION(SERIES NUMBER(S)PROVIDED]: <br /> YES 1:1 NO <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. I have reviewed and understand questions answered incorrectly with the issuing county. <br /> CERTIFIED P LICA T S TURE DATE SIGNEDICERTIFIED <br /> !fin 7 // — <br /> Distribution: Original County Canary—Certified Private Applicator Pink —Copy <br /> Adoo— Wd jo]eollddV elenud peygWeO—AreueO Atu / � IASI <br /> J �'J—I�:�O � qn Q d <br /> 1311H 0/03N S 31V0 3 S O1Y011ddV I 1311H30 <br /> -Ajunoo 5ulnssl eqj 4j!M AIjoaijoou!pejemsue suoljsenb puejsjapun pue paMalAaj ane4 I •sep!ollsed esn pejpulsaj jo asn jo/pue <br /> uo1ssessod eqj jol uolw <br /> jeuwexe uo!leolippeo jojeopddy ajenud e141 ua)/el aneq j jeyl pue IoaJJoo s!u09eUJJ0J1!anoge eqj Appeo I <br /> ON ❑ S3A ❑ <br /> I0301A08d(S)H38rinN S31H3S]NOIlVYRlOANI S31H3S A-33VS 3CI011S3d 0301AOHd NOIIVYYHO3NI S31H3S A.L33VS 301011S3d <br /> NOUVNIAVX3 Ai33VS HEINHOM N011VNIAVX3 IV133N30 <br /> :03nSSl NOIlY01311H30 <br /> Tull J :AB 03f1SSl iO4H3d/NOI1V01311H30 <br /> 839nnN 3NOHd A1NnO3 03nsS1 H39AnN lINIH3d 3AYN A1Nnoo UNIA311H30 <br /> SS3H00V <br /> H38nnN 3NOHd 8O1V01lddV 3tNVN 8O1V011ddY 31V, d <br /> � 6 ' �, / Z / <br /> 31VO N I1VHIdX3 NOI1V01311H30 <br /> (l6lL'1S3)ZCl-3N3-Hd <br /> 1N3W31d1S N011t/0I=1I1830 <br /> HONVHBIN3MI30803N3301011S3d bIO1V3I1dd`d 31VAIdd <br /> NCuv1n938 301011S3d 301N3W18Vd30 VIN80311V030 31V:S <br />