Laserfiche WebLink
.fef. <br /> 'Fxl✓ Hi:.f "W_ _6JRMATM <br /> Business Name(Same as Facility Name or DBA-Doing Business As) CERS ID <br /> Business Site Address City ZIP Code <br /> Z�Zc� iJ . G��u>"�ti �1 jr e t <br /> Name of Designated UST Operator Providing the Training(Print as shown on the ICC Certification.) <br /> 7—0 b o-'( t lvl , <br /> Mailing Address Phone# <br /> 2�Zv K), L ��r�iJo S-i. ��L �c.—��r• , C� . �5 _i,q IQ,, <br /> ICC Certification# ICCCercation Expiration Date <br /> tifi <br /> ltt. )=AOLIT'I EMPLE3YE :NFOR�IIA FtLI i _. <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 /> El 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 /> I axi <br /> to <br /> e - � ► -� <br /> "DIM ► � ` <br /> The facility employees listed above have completed the required training in accordance with Calhomia Code of Regulations, <br /> n <br /> Title 23,Division 3,Chapter 16,Section 2716(c)and all the information provided herein is accurate. <br /> Training Designat9ratSignature Date of Training <br /> �a! / / <br /> CERS=Ca6fwiia ErMmn rtental Reporting System,ID=Idertificabon,ICC=International Code Coundi,UST=Underground Storage Tank <br />