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i <br /> 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 Bust ass As.) CERS ID <br /> Business Site Address - _ � -- <br /> IL DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION � <br /> Name of Designated UST Operator Providing the Training (Print as shown on the fCC Certification.) - �_- <br /> Mailing Address _ Phon # <br /> �7 <br /> -.. . � 5` J <br /> ICC Certification li ICC Certification Expiration Date <br /> 4 /S� " - l o) it <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 Facility <br /> employee duties . Individuals assuming the duties of the facility employee on and after October 13, 2018 must be trained before performing <br /> facility employee duties , <br /> Check this box if a list of the individuals) trained is appended to this form. The appended list ata minimum must contain all of the <br /> information in this section. <br /> ii <br /> r Training Date ,' Date of Assuming <br /> Name of Individual(s ) Trained s a i r -� l4 , Responsibility as a <br /> 14 }'_ Facility Employee <br /> -- -- - - _ <br /> r c to � ls ` t < (o � � t .. 04 <br /> t_ b � ilyr N l � ii.IJ ` 7✓�� <br /> _ <br /> �T <br />, <br /> IS <br /> _ . _ <br /> - - i <br /> F <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 provide herein is accurate. <br /> Training Designated UST Operator Signature - Date of Training <br /> i <br /> CER, = California Environmental Reporting Systems, ID = Identification, ICC = Interrmioml Cc & Council, UST = Urxlsrground stiortige tank <br />