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UNDERGROUND STORAGE TANK <br /> FACILITY EMPLOYEE TRAINING CERTIFICATE (Page 1 of 1) <br /> 1. FACILITY INFORMATION <br /> Business Name(Same as F cility Nameor DBA-Doing Business As) CERS ID <br /> �^ �1 1 OX L4-L <br /> Business Site Address City ZIP Code <br /> Lo S b C fleSZvt:,:-,- "N b <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 /> Mailing Address Phone# <br /> .t S 'ate t-E-c--�--" B- <br /> ICC Certification# ICC Certification Expiration Date <br /> C '0-1 -:�r - Zq-i <br /> Ill. 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 /> El 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 Employee <br /> N L�� � •7� Su nL'4jA-� <br /> tj <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, Division 3, Chapter 16, Section 2715(c)and all the information provided herein is accurate. <br /> Training Designated U pera r 'gnature oo Date of Training <br /> CERS=California Environmental Reporting System,ID=Identification,ICC=International Code Council,UST=Underground Storage Tank <br />