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UNDERGROUND STORAGE TANK <br /> FACILITY EMPLOYEE TRAINING CERTIFICATE (Page 1 of 1) <br /> I. FACILITY INFORMATION <br /> Business Name(Same as Facility Name or DBA-Doing Business As) C€RS ID <br /> SAFEWAY 1769 10156809 <br /> Business Site Address City , ZIP Code <br /> 2802 COUNTRY CLUB BLVD iSTOCKTON 95204 <br /> if. DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br /> Name of Designated-UST Operator Providing the Training(Print as shown on the ICC Certification.) <br /> Rita Martinez <br /> Mailing Address Phone# <br /> 680 Quinn Ave San Jose CA 95112 (408)971-2445 <br /> ICC Certification# ICC Certification Expiration Date <br /> 9028811 1/25/21 <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 /> Ei 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 Employee <br /> Lisa Tam 5/30/2019 3/16/2010 <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 2716(c)and all the information provided herein is accurate. <br /> Training Designated UST Operator Signature Date of Training <br /> ryv` 5/30/19 <br /> CERS=California Environmental Reporting System,ID=Identification,ICC=International Code Council,UST=Underground Storage Tank <br />