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UNDERGROUND STORAGE TANK <br /> FACILITY EMPLOYEE TRAINING CERTIFICATE (Page 1 of 1) <br /> I. FACILITY INFORMATION <br /> Business Name(Same as Facility Name or DBA-Doing Business As) CERS IQ <br /> EI Dorado Market 10182043 <br /> Business Site Address City ZIP Code <br /> 1605 S E1 Dorado Stockton 195206 <br /> II. DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br /> Name of Designated UST Operator Providing the Training(Print as shown on the ICC Ceri lcation.) <br /> Karen R Arnaiz <br /> Mailing Address Phone# <br /> P.O Box 162 Lodi, CA. 95241 {209) 518-4836 <br /> ICC Certification# ECC Certification Expiration Date <br /> 8032295 2/3/2021 <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 <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 ifa list of the individual(s)trained is appended to this form. The appended list,at a minimum,must contain <br /> all of the information in this section. <br /> Date of Assuming <br /> Name of Individual(s)Trained Initial Training Date Responsibility as a <br /> Facility Employee <br /> IV. CERTIFICATION BY DESIGNATED UST OPERATOR CONDUCTING THIS TRAINING <br /> The facility a loyees listed above have completed the required training in accordance with California Code of Regulations, <br /> Title 23, Division 3,Chapter 16,Section 2715(c)and alt the information provided herein is accurate. <br /> TraininesigNated UST 0' or Signature Date of Train' g <br /> 6/25/2020 <br /> r <br /> CERS= is Envirorm Reporting System,li3= ,ICC=Intemabortal Code Camas,UST=tkidergra"Storage Tank <br />