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• 0 <br /> -�,.���,� MMPLQYEE'.TR"ING CRRTIF CATS(Page let 1) <br /> Business Name(Sarre ase Facility Neme or t7B I FACILITY INFORMATION <br /> A•Do1ng BUdIne33 A31 CERS ID <br /> Business Site Address M -T to �D SSG <br /> /09 �.�,� city z code <br /> 11. • <br /> DE$1aNATED:UNDEROROUND STORAGE TANK OPERATOR INFORMATION <br /> Name of Designate UST Operator peralor Providing the Training'(Print as shown on the ICC CerUlkallon:i <br /> ane,Nimrno <br /> Mailing Address <br /> 416 2nd Street Galt CA 9.56.32 Phone if <br /> ICC certification# MAI 744-0112 <br /> 8883064-UC ICC Certification Expiration Date 2/25/2020 <br /> FACILITY'EMPLOYEE INFORMATION <br /> Individuals assuming the duties of the facility employee before October 13,2018 must be trained within 30 days of performing <br /> facility employee duties.Individuals assuming the duties of the facility employee on and after October 13,2018 must be trained <br /> before performing facility employee duties. <br /> a Check this box if a list of the individual(s)trained is appended to this form. The appended list,at a minimum,must contain <br /> all of the information in this section. <br /> Date of Assuming <br /> Name of Individual(s)Trained Initial Training Date Responsibility as a <br /> Facility Employes <br /> 2_D 0 It <br /> /j l�v i�vD yl Si,� fy a <br /> UlJ AV_ 2. 0 70"47f8 <br /> —, ko(6i <br /> s <br /> i <br /> I <br /> ; i <br /> i <br /> i <br /> IV CERTIFItCATION BY DESIGNATED UST OPERATOR CONDUCTING THIS TRAINING <br /> aslisted above have completed the required training in accordance with California Code of Regulation <br /> The facility employ <br /> ction 2716{c)and all the information provided herein is accurate. <br /> Title 23,Division 3,Chapter 16,Se <br /> Training Designated UST Operator Signature _ Date of Training <br /> System,iD-Iden*S§OniCC-I tlp181.Code @T� ound Storage Tank <br /> CERS=California en <br /> mtal Rep _ - <br />