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06 / 28 / 2019 19 : 29 8387674 Ehr1ILS PAGE 28
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<br /> Business Name (same as Facf fy Name or ABA-Doing Business As) CPRS ID
<br /> Emils Liquor & Sports Sho 10180567
<br /> 1usiness Site Address City ZIP Code
<br /> 1405 California Street Escalon 95320
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<br /> Name of Designated UST Operator Providing the Training (Print as shown on the ICC Cert cation.)
<br /> Dave Winkler
<br /> Mailing Address Phone #
<br /> 416 2nd Street Galt CA 95632 209 7440112
<br /> ICC Certification # ICC Certification Explration Date
<br /> 8883059- UC 2/23/2020
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<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 individuaf(s) trained is appended to tills form. The appended list, at a minimum, must contain
<br /> all of the information in this section.
<br /> Date of Assuming
<br /> .� Q � '" Name of Individual(a) Trained Initial Training Date Responsibility as a
<br /> Facility Employes
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<br /> Pi it it `r';:',rF" i7�' . Q'9' iIF S,f, /1T4r �u '.I'll # kCJ : KrQNpUC«TtN©. THtS :TFih1NMNG
<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 271 nd all the information provided herein is accurate .
<br /> Training Designated UST operator Signature bats of Tr ining � '
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<br /> CER9 = California E Aron cental Repor*V System, ID = Iden on, ICC = Intemational Code Council, UST = UndeRy> l Storage Tank
<br /> Received Time Jun , 28 . 2019 7127PM No , 5223
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