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UNDERGROUND STORAGE TANK <br /> FACILITY EMPLOYEE TRAINING CERTIFICATE(Page 1 of 1) <br /> -- L FACILITY INFORMATION <br /> —T <br /> Business Name(Same as Facility Name or DBA-Doing Business As) CC—ERS ID <br /> SAFEWAY 1769 10156809 <br /> Business Site Address City ZIP Code <br /> 2802 COUNTRY CLUB BLVD STOCKTON 95204 <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 /> Rita Martinez <br /> P—ailing Address Phone# <br /> 680 Quinn Ave San Jose CA 95112 408-971-2445 <br /> ICC Certification# ICC Certification Expiration Date <br /> 9028811 1/26/21 <br /> 111. 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)framed 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 Responsibility Initial Training Date P Y as a <br /> Facility Employee <br /> LASHANTE LEWIS 11/12/2019 11/12/2019 <br /> -- I <br /> IV. CERTIFICATION BY DESIGNATED UST OPERATOR CONDUCTING THIS TRAINING <br /> I 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 UST Operator Signature Date of Training <br /> 11/12119 <br /> CERS=California Environmental Reporting System,ID=Identification,ICC=International Code Coundl,UST=Underground Storage Tank <br />