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UNDERGROUND STORAGE TANK <br /> FACILITY EMPLOYEE TRAINING CERTIFICATE (Page 1 of 1 ) <br /> 11 <br /> I. FACILITY INFORMATION <br /> Business Name (Same as FacilityNama or DBA-Doing BusinessAs.) CERS ID <br /> TRACY UNIFIED SCHOOL DISTRICT 110181579 <br /> Business Site AddressCity ZIP Code <br /> 1975 W. LOWELL AVE TRACY 95376 <br /> IL DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br /> Name of Designated UST Operator Providing the Training (Print as shown on the /CC CertiFcation.) <br /> ANDY BAGLEY <br /> Mailing Address T Phone # <br /> 2370 MAGGIO CIRCLE #4, LODI , CA 95240 209 367 - 4800 Ext. <br /> ICC Certification # ICC Certification Expiration Date <br /> 8012449 07/19/2020 <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 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 individual(s) trained is appended to this form. The appended list at a minimum must contain all of the <br /> information in this section. <br /> Initial Training Date Date of Assuming <br /> Name of Individual(s) Trained Responsibility as a <br /> Facility Employee <br /> i„ <br /> s <br /> Y 'fit <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 provide herein is accurate. <br /> Training Designated UST Operator Signature Date of Training <br /> CERS = California Environmental Reporting Systems, ID = Identification, ICC = International Code Council, UST = Underground storage tank <br />