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UNDERGROUND STORAGE TANK <br /> FACILITY EMPLOYEE TRAINING CERTIFICATE (Page 1 of 1) <br /> I. FACILITY INFORMATION <br /> BuSe�ss Name <br /> \(Same as Facility Name or DBA-Doing Business As) CERS ID <br /> Business Site Address City ZIP_ Code <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 /> Felix Ramirez <br /> Mailing Address Phone# <br /> 416 2nd Street Galt CA 95632 209 744-0112 <br /> ICC Certification# ICC Certification Expiration Date <br /> 8883072-UC 3/1/2020 <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 <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,ata 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 /> iA <br /> 0C( o. - .• I <br /> J4L,4�c,- - ZvZU -2c, 2-c <br /> Ubui 2-,01'R" <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 /> Title 23, Division 3, Chapter 16,Section 2715(c)and all the information provided herein is accurate. <br /> Training Designated UST Operator Signature r Date of Training <br /> r -f: C'�2 / 11 <br /> - 1z <br /> CERS=Califomia Environmental Reporting System,ID=Identification,ICC=Intemational Code Council,UST=Underground Storage Tank <br />