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UNDERGROUND STORAGE TANK <br /> FACILITY EMPLOYEE TRAINING CERTIFICATE (Page 1 of 1) <br /> 1. FACILITY INFORMATION <br /> ............. <br /> 1 Business Name(Same as Facility Name or DBA-Doing Business As) CERS ID <br /> Pacific Avenue Chevron <br /> 10594654 <br /> r Business Site Address- --- City ZIP Code <br /> 6633 Pacific Avenue IStockton 195207 1 <br /> 11. DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br /> Name of Designated UST Operator Providing the Training(Print as shown on the ICC Certification.) <br /> Michael Reimers / Stephanie Murphy (209-380-5542) <br /> ................. __ __ . <br /> Mailing Address Phone# <br /> PO Box 1096 Carmichael CA 95609 (916) 967-2279 <br /> ICC Certification# ICC Certification Expiration Date <br /> 8289276 I t 1 8/20/2020 <br /> III. FACILITY EM LOYEE INFORMATION <br /> .......... <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 /> ........... <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 <br /> uu all of the information in this section. <br /> ............. -t <br /> Name of Individual(s)Trained <br /> M 4, C U! <br /> Aared (A)d1jqMS' <br /> Sept -),c)/I Feb <br /> � 11q <br /> /�l %ky 12c, 211qlZV <br /> ZIZIV 1-p�' <br /> Ck Q M03(b V4&V-A <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 Code of Regulations, <br /> Title 23, Division 3, Chapter 16, Section 2715(c)and all the information provided herein is accurate. <br /> Training.PeStwated U§J--Qper4tor Signature Date of Training <br />