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RECEIVED <br /> By Carol Presto at 3:46 pm,May 06, 2021 <br /> UNDERGROUND STORAGE TANK <br /> FACILITY EMPLOYEE TRAINING CERTIFICATE (Page 1 of 1) <br /> I. FACILITY INFORMATION <br /> Busine s Name(same as Facility Name or DBA,,Dolng Business As) <br /> CERS ID <br /> Busine s site 7 els 7 �' Ci _ <br /> '� ZIP Code <br /> `V �' <br /> I!• DES! NATER NDERGROUND STORAGE TANK OPERATOR INFORMATION <br /> Name f Designated U 7 O erator Providing TTraining(Print as shown on the ICC Certification+ <br /> Mailing ddress <br /> PO Box 933, West Sacramento, Ca 95605 Phone# <br /> ICC Ce�tlfication# 916 371-2380 <br /> ,� / - ICC Certification Expir on Da Ld <br /> "70 ���. LZ <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 /> ❑ C peck this box if a list of the individuals)trained is appended to this form. The appended list,at a minimum, must contain <br /> al of the information in this section. <br /> Name of Individuals}Trained Date of Assuming j <br /> Initial Training Date Responsibility as a <br /> Facility Employee <br /> 17 <br /> 11,'. CEER"TirriCATlON tsr DES IGNATED 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)a d'alf the information provided herein is accurate. <br /> Training esrgnated UST Operator Sign a'tt Date of Trams <br /> xl) <br /> CERS=Call lomia Environmental Reporting System,ID=Identification,ICC=International Code Council,UST=Underground Storage Tank <br />