Form PR-PML-170 "Liability Certification Statement" - California

What Is Form PR-PML-170?

This is a legal form that was released by the California Department of Pesticide Regulation - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2003;
  • The latest edition provided by the California Department of Pesticide Regulation;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form PR-PML-170 by clicking the link below or browse more documents and templates provided by the California Department of Pesticide Regulation.

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Download Form PR-PML-170 "Liability Certification Statement" - California

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STATE OF CALIFORNIA
PEST MANAGEMENT AND LICENSING BRANCH
DEPARTMENT OF PESTICIDE REGULATION
1001 I STREET
SACRAMENTO, CA 95814-2828
LIABILITY CERTIFICATION STATEMENT
P.O. BOX 4015
MAINTENANCE GARDENER PEST CONTROL
SACRAMENTO, CA 95812-4015
BUSINESS LICENSE
(916) 445-4038
PR-PML-170 (REV. 7/03)
FAX (916) 445-4033
Web site: http://www.cdpr.ca.gov
I,
certify that I engage in pest control for hire as
an incidental part of my regular Maintenance Gardening business.
I will respond to any damages I may cause while performing activities through the use of my own personal
assets.
I certify that there are no unpaid judgments against my company resulting from lawsuits filed against the
business.
I certify that there are no current lawsuits filed against my company relating to pest control activities.
I certify that there are no liens on my personal or real property due to unpaid taxes.
THE BUSINESS NAME IS
I DECLARE UNDER PENALTY OF PERJURY, UNDER THE LAWS OF THE STATE OF CALIFORNIA,
THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE
DATE
STATE OF CALIFORNIA
PEST MANAGEMENT AND LICENSING BRANCH
DEPARTMENT OF PESTICIDE REGULATION
1001 I STREET
SACRAMENTO, CA 95814-2828
LIABILITY CERTIFICATION STATEMENT
P.O. BOX 4015
MAINTENANCE GARDENER PEST CONTROL
SACRAMENTO, CA 95812-4015
BUSINESS LICENSE
(916) 445-4038
PR-PML-170 (REV. 7/03)
FAX (916) 445-4033
Web site: http://www.cdpr.ca.gov
I,
certify that I engage in pest control for hire as
an incidental part of my regular Maintenance Gardening business.
I will respond to any damages I may cause while performing activities through the use of my own personal
assets.
I certify that there are no unpaid judgments against my company resulting from lawsuits filed against the
business.
I certify that there are no current lawsuits filed against my company relating to pest control activities.
I certify that there are no liens on my personal or real property due to unpaid taxes.
THE BUSINESS NAME IS
I DECLARE UNDER PENALTY OF PERJURY, UNDER THE LAWS OF THE STATE OF CALIFORNIA,
THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE
DATE