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UNDERGROUND STORAGE TANK <br /> FACILITY EMPLOYEE TRAINING CERTIFICATE (page 1 of 1) <br /> I. FACILITY INFORMATION <br /> Business Name(Same as Facility Name or DBA-Doing Business As) CERS ID <br /> Short Stop 76 J10180633 <br /> Business Site Address City ZIP Code <br /> 20 West Turner Road Lodi 195240 <br /> Il. 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 /> 537 Amherst Court, San Ramon, CA 94583 925 389 - 1262 Ext. <br /> ICC Certification# ICC Certification Expiration Date <br /> 5243897-UC 9/2/22 <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 13,2018 must be trained before performing <br /> facility employee duties. <br /> L] Check this box N a list of the individuals)trained is appended to this form. The appended list at a minimum must contain aU 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 /> Harjeet Singh 11/16/19 11/17/19 <br /> Lakhwinder Sandhu 4/7/17 4/7/17 <br /> Amritpai Singh 2121/20 2/22/20 <br /> Iv. CERTIFICATION BY DESIGNATED UST OPERATOR CONDUCTING THIS TRAINING <br /> The facility employees listed above have compNted 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 heroin is accurate. <br /> Training Designated UST Operator Signature Date of Training <br /> 4 • 8/20121 ./ <br /> 100 <br /> cERs=caiiomw&wkmn a gm Rep-thgSysbmukD■Idwr0eetl1 ICC■tMetnsam ' Code cane,USTmtindeWardsbrapetask <br />