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04 / 26 / 2019 16 : 54 5107963470 SHARMA PAGE 05 <br /> N <br /> UNDERGROUND 91TORAGE TANK <br /> FACILITY EMPLOYEE TINJt4e GERTIFICd�W (Paool Of 1 ) <br /> I. <br /> FACILITY I�lFORMATIOT CERS ID <br /> 3ugine+ss �lart7o {Smin© as �acilfly Nance of DBA-C7Qi usiness As. P tai �r <br /> City as <br /> Rusin ss8itoAddFeas d wo � f _� �� w z� "� �J��—�j� <br /> II. DESIGN .ATED UNDERGROUND STOR,AQE4TANK OPERA`fQR INFORMATION <br /> Name W@®stgnatad livl Oper®tor Providing the Training (Pant gs shown on the. ICC Ce�ication ) <br /> t� �4..X" � ' •N— lhono <br /> Mailing Address F ` C vk ; r te) V" ] ,d5 d - ` � �ctM i! <br /> Certification Expiration Date <br /> tCG Cerkcatiory t " ,r <br /> _ Ill . . FACILITY EMPLOYEE INFORMATION <br /> cility <br /> Indivlduais ased Nwitroln 30 days of <br /> sumltt8 the duties Cumin facility the uPiestofe fuo Eefore october 13 ,i"" etx►ployee or+oand after ctn@er 3, 2048 m � trained beTOCeforining apePPoemir► g <br /> employee duties _ lndnlidu»ls esa 9 4 <br /> facility employee dutlee . <br /> Check this box if alist o�dual(s) trained is appended to this ll 740 @PPOnd�lii lis-t st a mli'rlmur" mlis8 eoritgin all of the <br /> a Information in this section. <br /> -- - initial Training Dam [)ate of Assuming ; <br /> � � Reapot�sibil'rty as <br /> Hama of Indiuidusl(s) Trained kl l "TF ti;tm Facift Employee i <br /> -�— <br /> A .. ....... r I, <br /> haw <br /> rrL 19 <br /> - -- _ 1 z <br /> 040 <br /> Ll <br /> �I <br /> Iii, CERTIFICATION BY DESIGNATED UST OPERATOR CONDUCTING THIS TRAINING � 4� <br /> faC111 y employiii Ii>; Wd above have oorrjpWWd tho required training 1P acoordanca ii California CAdO Of Regulatio <br /> title 23, division 3. chapter 16, section 2715(c) and all the information prOvide herein ie aCCurate. l <br /> YEale otTl ��g5' l <br /> Training DeEignatad USTOperator Signature <br /> J2 te " AA_ <br /> t }i <br /> Received Time Apr , 26 . 2019 6 . 52PM Noll r <br /> r ; �aitTamdx� Envlaonrnerdal Repmorig SpWinvei, ID m We, tifta0m, W t,gta►rOVOM Code Cvttnsa't, UST kkc� sago twk �a <br /> E <br />