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UNDERGROUND STORAGE TANK <br />FACILITY EMPLOYEE TRAINING CERTIFICATE (Page 1 of 1) <br />L FACILITY INFORMATION <br />CERS = Caltwia Environmental Reporting System, ID = Ident[fi:Mb joc = Intemational Code Council, UST = Undergmund Storage Tank <br />(S <br />Business Name ame as Facility Name or DBA -Doing Business As) <br />Main Street Fuel Circle K <br />CERS ID <br />10181307 <br />Business Site Address <br />419 S. Main <br />City <br />Manteca <br />I ZIP Code <br />95337 <br />II. DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br />Name of Designated UST Operator Providing the Training (Print as shown on the ICC Certification.) <br />Karen R Arnaiz <br />Mailing Address <br />P.O Box 162 Lodi, CA, 95241 <br />Phone # <br />209 5184836 <br />ICC Certification # <br />8032295 <br />ICC Certification Expiration Date <br />2/3/2021 <br />111. 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 If a list of the Individuals) trained Is appended to this form. The appended list, at a minimum, must contain <br />all of the information in this section. <br />Name of Individual(s) Trained <br />Initial Training Date <br />Date of Assuming <br />Responsibility as a <br />Facility Employee <br />G/(] <br />l <br />r C�i <br />C2 D <br />IV. CERTIFICATION BY DESIGNATED UST OPERATOR CONDUCTING THIS TRAINING <br />The facility employees listed above have completed the required training in accordance with California <br />Title 23, Division 3, Chapter 16, Section 2715(c) and all the information provided herein is accurate. <br />Code of Regulations, <br />Training Desigpated US perstor Si to <br />Date of Training <br />1/8/2020 <br />