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UNDERGROUND STORAGE TANK <br /> FACILITY EMPLOYEE TRAINING CERTIFICATE (Pagel of 1) <br /> 1. FACILE- Y INFORMATION _ <br /> Business Name(Same as Facility Name or DBA-Doing Business As) 710180797 <br /> ERS ID <br /> Quick Stop Market ej <br /> Business Site Address _ _ City ZIP Code <br /> � d 4 S i �2 <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 /> Harold Largo Jr <br /> Mailing Address Phone# <br /> 3900 Commerce Way 372-1888 <br /> ICC Certification# ICC Certification Expiration Date <br /> 8293993 9/30/2020 <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 tc this form. The appended fist,at a minimum,must contain <br /> El 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 /> 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 Training <br /> CERS=California Environmental Repotting System,ID=�14cati,n,M�lntemafional Code Council,UST=Underground Storage Tank <br />