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UNDERGROUND STORAGE TANK <br /> FACILITY EMPLOYEE TRAINING.CERTIFICATE(paw f of 1) <br /> 1. FACILITY INFORKAT'tt N <br /> Business Name(Same as Facility Narne or DBA-Doing Business As) <br /> T <br /> ERS ID <br /> Pacific Avenge Chevron 10594654 <br /> Business Site Address city ZIP code <br /> 6633 Pacific Avenue Stockton 95207 <br /> H. DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORIIIIA11014 <br /> Dame of Designated UST Operator Providing the Training(forint as shown on the[CC Certification.) <br /> Stephanie Murphy <br /> Mauling Address Ptrone <br /> PO Box 1096 Carmichael CA 95609 209) 380-5542 <br /> ICC Certification# IGC Cerfficafron Expiration Date <br /> 9383552 10/112021 <br /> Iii. FACILITY EMPLOYEE.INFORKATION <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 /> o 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 /> Date of Assuming <br /> Name of Individual(s)Trained Initial Training Date Responsibility as a <br /> Facility Employee <br /> Tracy Shaw 11/1812020 11/18/2020 <br /> Sara Belasco 11118/2020 1111812020 <br /> Simone Benoit 11/18/2020 11/1812024 <br /> E <br /> N. CERTIFICATION BY DESIGNATED UST OPERATOR CONDUCTING TICS TRAINING <br /> The facility employees lusted 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 /> Train! signated UST Operator Signature Date of Training <br /> 11/18/2020 <br /> I RS= ' 8wirmrontW Rap"V Systern,m= rx=irsernabonal Code coum*UST=Undergmund Storage Tarn <br />