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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 /> Short Stop 76 10180633 <br /> Business Site Address I City I ZIP Code <br /> 20 West Tumer Road I Lodi 195240 <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 /> Alex A. Jabbari <br /> Mailing Address Phone# <br /> 9'27 Amhnrcf r nâ–șirt Can P:3mnn r..A QdriRq Ina _ 19A9 c r <br /> ICC Certification# T ICC Certification Expiration Date <br /> 5243897-UC 1 10/1/2020 <br /> 111. 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 13,2018 must be trained before performing <br /> facility employee duties. <br /> Check this box if a list of the individuals)trained is appended to this form. The appended list at a minimum must contain all of the <br /> information in this secSon. <br /> Initial Training Date Date of Assuming <br /> Name of Individual(s)Trained Responsibility as a <br /> Facility Employee <br /> Harjeet Singh 11/16/19 11/18/19 <br /> IV. CERTIFICATION BY DESIGNATED UST OPERATOR CONDUCTING THIS TRAINING <br /> The facility employees listed above have completed the required training in accordance with Califomia 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 /> 11/16/19 <br /> CERS=Caliomia Environmm al Reportrrg Sysbmwn 10='I 1111iea6on,ICC=kr +national Cade Council/,USF=Underground storage tank <br />