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• F-s <br /> I I canfopnia class <br /> POWERED B'f Petroleum Training <br /> c 50tutions UST OpepatoP <br /> Facih Specific Worksheet <br /> The purpose of this worksheet is to document that Class C Operators have been trained on facility-specific underground storage tank (UST) <br /> components . This worksheet must be completed at the facility where the Class C Operator will be working to complete the training provided <br /> by the online course, `Fueling Station Safety. ' This worksheet must be completed BEFORE the Class C Operator assumes responsibility for <br /> responding to emergencie and dispensing a regulated subp., i( <br /> UST Facility Name . e l`�V/ UST Facili ID # <br /> UST Facility Address <br /> C�> nLwsDo � � � <br /> gool <br /> ave shown the Class C Operator the Emergency Shut-off Switch . <br /> NATE: the e>ziergensy,:stop . vtiictrshitts;-0,ff {�gw.erto alFllie:. i ►ts$rsartfuetpt�!�Ps the etnergeticystnp switch Isdif#Brent <br /> � qp^ of SII Stop? �ttttop yn ttre;point >7f iale:fP ; oohspt& Ttie emer >inoy ;tap switgh .is i egwreil .by natitinai fire codes. <br /> ttontaeta :cjuatr el( petreleum stor2ge_ systeinservice dobtractor-i ou:cannatlocate :tW merge Ystop swrtth. <br /> 100 I have shown the Class C Operator the number to use to call the fire department for this facility and posted this number in a clearly <br /> visible location . <br /> d400rlave shown the Class C Operator the list of company people who should be notified in an emergency and posted the list in a <br /> rly visible location . <br /> I have shown the Class C Operator the tank monitor and provided instructions on how to respond to various alarm messages that <br /> may appear on the display. 416M%I_. • . <br /> NOTE Mil) datToi'tCnnw. tibv� tb.rdad �he displ: tl ortvha t ?cpeet°if tt- I I i-a prnbfbm i <br /> arrlth tie stncage sysxem; . <br /> look 'in : hp tank monitor, manual tofind .. . . fhformattor4 .i'nr. caI( a gpolifiedjietrofeum syst+tm enhtractor and have him of. her e#la.ln this <br /> iiiformatiotlffo you : <br /> have shown the Class C Operator the locations and proper identification of the following items; <br /> Cj,OODrpenser2 <br /> moose <br /> ❑ Nozzle <br /> ❑ Breakaway Coupling <br /> N s <br /> rel: emergency Shut- off Switch <br /> � � <br /> �riill Alarm (if applicable) <br /> 'OIL A CLASS C UST OPERATOR MUST BE OWSITE AT ALL TIMES DURING NORMAL BUSINESS HOURS <br /> a I hereby certify I have completed this worksheet together with the Class C Operator: <br /> MMM <br /> we I ' V- � Date: <br /> Designated Class A or B Operator Name: <br /> u Designated Class A or B Operator Signature : ` <br /> I have completed this workshe gether WithTnern named abov ,{ <br /> '14 � G1- � 0 — Date: � D ' <br /> Class C Operator Name : <br /> _ Class C Operator Signature : <br /> KEEP THIS pOCUMENT ON -SITE AT ALL TIMES <br /> PJ ll5f Training <br />