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322 S. Center St, Stockton, Ca 95203 <br /> 03/18/2021 Program: UST <br /> PHOTO 1: <br /> Training for site emplo ee was provided after date of assuming responsibility <br /> UNDERGROUND STORAGE TANK <br /> FACILITY EMPLOYEE TRAINING CERTIFICATE(Paget oft) <br /> I. FACILITY INFORMATION <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> Tt=.nited Stj tj CERS ID <br /> 1 iness Site gtldress S. <br /> City /t7 10-N 3 t! <br /> c3 Z Z ZIP Code Gel•, or �Sf. <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 /> Evangelina Barroso-Traylor <br /> Mailing Address <br /> 3960 Gruenhagen Flat Paso Robles,Ca.93446 Phones <br /> (909)455-2275 <br /> ICC Certification# ICC Certification Expiration Date <br /> 8200889 2/25/2001 <br /> 111. 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 /> L �LL web zoaD <br /> U <br /> I <br /> z <br /> U <br /> L <br /> IV. CERTIFICATION BY DESIGNATED UST OPERATOR CONDUCTING THIS TRAINING <br /> 'e facility employees listed above have completed the required training in accordance with California Code of Regulations, <br /> e 23,Division 3,Chapter 16,Section 2715(c)and all the Information provided herein is accurate. <br /> Date of Trdu;Infi <br /> "'III Trai n Designated T Operator Signature <br /> a� <br /> CERS=Calk)rnia Environmental Reporting System,ID=Identifiratbn,ICC=Intemaboml Cade Council,UST=Underground Sbxage Taut 1 N•Rev.10101118 r <br /> www.unidocs.org <br /> VICKY VANG-LEE, EHS Page 1 of 1 <br />