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UNDERGROUND STORAGE TANK <br /> FACILITY EMPLOYEE TRAINING CERTIFICATE (Pagel of 1) <br /> I. FACILITY INFORMATION <br /> Business Name(Same as Facility Name or DBA-Doing Business As) CERS ID <br /> Rancho San Miguel 10184829 <br /> Business Site AddressCity ZIP Code <br /> 1427 Airport Way Stockton 195206 <br /> II. DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br /> Name of Designated UST Operator Providing the Training(Print as shown on the ICC Certification.) <br /> Karen R Arnaiz <br /> Mailing Address Phone# <br /> P.O Box 162 Lodi, CA. 95241 209) 518-4836 <br /> ICC Certification# ICC Certification Expiration Date <br /> 8032295 2/3/2021 <br /> III. 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 /> 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 /> qn <br /> Facility Employee <br /> j LSv\�Gt— 1v U1 Lj f Z p` <br /> 2DC) <br /> GYl <br /> L.)v � �� - R- Jq=Iq 3 -Iq-1 <br /> Uu-vr� <br /> IV. CERTIFICATION BY DESIGNATED UST OPERATOR CONDUCTING THIS TRAINING <br /> The facility employees listed above have completed the required training in accordance with California Code of Regulations, <br /> Title 23, Divisi7 3, Chapter 16, Section 2715(c)and all the information provided herein is accurate. <br /> Training-Des' i;ted UST Operator Signature Date of Training <br /> 5/13/2020 <br /> CERS=California Environmental Reporting System,ID=Identification,l6t� ational Code Council,UST=Underground Storage Tank <br />