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UNUtt(Gk0uNU J1URAGE LANK <br /> FACILITY EMPLOYEE TRAINING CERTIFICATE (Pagel of 1) <br /> I. FACILITY INFORMATION <br /> Business Name(Same as Facilely Name or DBA-Doing Business As) CERS ID <br /> Short Stop 76 10180633 <br /> Business Site Address I City I ZJP Code <br /> 20 West Tumer Road I Lodi 195240 <br /> IL DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br /> Name of Designated UST Operator Providing the Training(Print as shown on the fCC Certification) <br /> Alex A. .labbari <br /> Mailing Address Phone#9x, <br /> r.�7 Amhoret ( noir+ Can Ramnti <br /> n !`4 QdR /09x,1 'APO 7 <br /> R0_ 19R �.► <br /> ICC Certification#f ICC Certification Expiration Date <br /> 5243897-UC 10/1/2020 <br /> III. FACILITY EMPLOYEE INFORMATION <br /> individuals assuming the duties of the facility employee before October 13,2018 must be trained within 30 days of performing facility <br /> employee duties. Individuals assuming the duties of the facility employee on and after October 13,2016 must be trained before performing <br /> facility employee duties. <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 alt of the <br /> information in this section. <br /> Initial Training Date Date of Assuming <br /> Name of Individual(s)Trained Responsibility as a <br /> Facility Employee <br /> Amritpal Singh 2112120 2!13120 <br /> IV. CERTIFICATION BY DESIGNATED UST OPERATOR CONDUCTING THIS TRAINING <br /> The facility employees listed above have complelled the required training in accordance with California Code of Regulations, <br /> title 23, division 3,chapter 16,section 2715(c)and all the information provide herein is accurate. <br /> Training Designated UST Operator Signature''// Date of Training <br /> 2112120 <br /> CERS=Calffom is Envbonrrhahtal Repor ig Systaris,D=IderltTiCode CotnrJi,UST=lihdergrouhd storage tank <br />