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UNDERGROUND STORAGE TANK <br /> FACILITY EMPLOYEE TRAINING CERTIFICATE If 1 of 1) <br /> I. FACII_i''TY INFORMATION <br /> Business Name(Same as Facility Name or DBA-Doing Business As) CERS ID <br /> Pacific Avenue Chevron 10594654 <br /> Business Site Address City ZIP Code <br /> 6633 Pacific Avenue Stockton 195207 <br /> ll.- DESIGNATE€?UNDF-RGR04JKD STORAGE TANK OPERATOR INFORMATION <br /> Narne of Designated LAST Operator Providing the Training(taint as shown on the ICC Certification.) <br /> Stephanie Murphy <br /> Mailing Address Phone <br /> PO Bax 1096 Carmichael CA 95609 (2U9 380-5542 <br /> ICC Certification# ICC Certification Expiration{late <br /> 9383552 10/1/2021 <br /> M. FACILITY EMPLOYES INFORMATION <br /> Individuals assuming the dudes 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 13,20'18 must be trained <br /> before performing facility employee dudes. <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 /> all of the information in this section. <br /> Date of Assuming <br /> Name of Individual(s)Trained initial Training Date Rrrsponelbliity as a <br /> Facility Employee <br /> Timothy Taylor 10117/2020 10117/2020 <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 /> Tide 23,Division 3,Chapter 18,Section 271 5(c)and all the information provided herein is accurate. <br /> T Designated UST Operator Signature aat+r of Training 10/17/2020 <br /> CERS=Gail Emiironmental Reporting System,ID= ICC=Irw*tonal Code Couna UST=uixle round Storage Tarn <br />