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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) CERS ID <br /> West Valley Auto Servcie LLC -7 10184725 <br /> Business Site Address City ZIP Code <br /> 2615 W Grant Line Road Tracy J95304 <br /> 11. DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br /> Name of Designated UST Operator Providing the Training (Print as shown on the ICC Certification.) <br /> Rick Branchini <br /> Mailing Address Phone # <br /> 106 Wessex Way Folsom , CA 95630 925 699- 1396 <br /> ICC Certification # ICC Certification Expiration Date <br /> 81649$6 6!2/2020 <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 /> 0 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 /> Selena Alexis Ponce 10/22/2020 11 /2/2020 <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 UST Operator Signature Date of Training <br /> r3u 10/22/2020 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = Intemational Code Council, UST = Underground Storage Tank <br /> UNA 12 wwwounidocs.org 1I1 - Rev. 10/01 /18 <br />