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<br /> Name of Designated UST Operator Providing the Training (Print as shown o» the ICC Certification.)
<br /> Melling Address Phone #
<br /> PO Box 933 , West Sacramento , Ca 95605 9 '16 371 -2380
<br /> ICC Cartification # ICG' Certification Expiration pate
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<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 thh t box if a.list of the lndividualis) trained is anperided to this form. The appended list at a minimum, must contain
<br /> �-•r! alt orf the Informatlan in 'tttis section_ '
<br /> bate of Assuming
<br /> Name of Individual(s) Trained Initial Training Date Responsibility as a
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<br /> The facility employees listed above have completed the required training in accordance with California Code of Regulations,
<br /> Title 23, Division 3, Chapter 18, Section 2715(c) and all the Information provided herein Is accurate.
<br /> Training Designated UST Operator Signature Date of Training
<br /> j CERS = Cafomia Environmental Reporting System, ID = IdentMwWon, IGC = Intan,iaiianal Code Council, UST = Underground Storage Tank
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