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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 ib <br /> 7-Eleven 35355 1 10166191 <br /> Business Site Address City ZIP Code <br /> 3202 W. Hammer Lane Stockton 95209 <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 /> Kevin Dutra <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 /> 9273805 7/2912021 <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 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 Date of Toning <br /> luh� � 2420 <br /> CERS=Cafifo nia Env unmental Reporting System,ID=Identification,ECC=International Code Council,UST=Underground Storage Tank <br /> 7-11 -35355 <br />