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UNDERGROUND STORAGE TANK <br /> FACILITY EMPLOYEE TRAINING CERTIFICATE (Page 1 of 1) <br /> 1. FACILITY INFORMATION <br /> Business Name(Same as Facility Name or DBA-Doing Business As) CERS ID <br /> Pacific Avenue Chevron 10594654 <br /> —6- Cit <br /> Business Site Address ZIP Code <br /> 95207 <br /> 6633 Pacific Avenue Stockton I <br /> 11. DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br /> Name of Designated UST Operator Providing the Training(Print as shown on the/CC Certification.) <br /> Stephanie Murphy <br /> ——--------- <br /> Mailing Address Phone# <br /> PO Box 1096 Carmichael CA 95609 (209) 380-5542 <br /> ICC,Certification# ICC Certification Expiration Date <br /> 9383552 10/1/2021 <br /> III. FACILITY EMPLOYEE INFORMATION <br /> I Individuals assuming the duties of the facility employee before October 13,2018 must be trained within 30 days of performing <br /> I facility employee duties.Individuals assuming the duties of the facility employee on and after October 13,2018 must be trained <br /> I before performing facility employee duties. <br /> F, 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 /> all of the information in this section. <br /> Name of Individual(s)Trained <br /> 3'1 <br /> 112-G0 16' 17-202-6 <br /> zc <br /> 'N- <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 S <br /> gnated T Operator Signature Date of Training <br /> (11 T- VA J At <br /> CERS=Ca-16.Envirorimentl Re�System,ID=WIL�-C(4 Iryterriabonal Code Cound,UST=Underground Storage Tank <br />