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UNDERGROUND STORAGE TANK <br /> FACILITY EMPLOYEE TRAINING CERTIFICATE ( Page 1 of 1 ) <br /> I . FACILITY INFORMATION <br /> Business me as Facility N or DBA-Doing Business As.) CERS ID <br /> Gi'� Co e <br /> Busine s ddr s Ci <br /> II . DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br /> Name of esi ted UST O erator Providing Trainin P/Xnt as shown on the ICC Certification.) <br /> P ne # <br /> M ilin Address (� � ; 459 Ext, <br /> ICC Certific tion ICC Certification Expiration Date <br /> III,C7Z 160 Q <br /> 11 . ^ 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 /> won, 0 <br /> i <br /> f <br /> 3 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, divisio 3 , chapter 16 , section 2715 (c) and all the information provide herein is accurate . <br /> Training De i ated U Operator Signature Date of Training~ ? _ Lid <br />