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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 /> Costco Wholesale- LODI - 1091 10146151 <br /> Business Site Address City ZIP Code <br /> 2680 Reynolds Ranch Pkwy Lodi 95240 <br /> II. DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br /> Name of Designated UST Operator Providing the Training (Print as shown on the ICC Certification.) <br /> Michael Moore <br /> Mailing Address Phone# <br /> 25971 Towne Centre Dr. South Foothill Ranch CA 92610 949 460-5200 <br /> ICC Certification# ICC Certification Expiration Date <br /> 9495322 1 12/17/2021 <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 <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 /> ® 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 Responsibility as a <br /> Facility Employee <br /> See Appended List <br /> IV. CERTIFICATION BY D IG T ST OPERATOR CONDUCTING THIS TRAINING <br /> The facility employees listed above hav#1cya/// <br /> r quired training in accordance with Califor Code egulations, <br /> Title 23, Division 3,Chapter 16, Section 2t e i formation provided herein is accurate. 7 <br /> Training Designated UST Operator Signature D to Ti i n� <br /> CERS=Caidomia Environmental Reporting System,ID=Idenfik;ation,ECC=International Code Council,UST=Underground Storage Tank <br /> COSTCO-1091 <br />