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RECEIVED 7/7/2021 <br />UNDERGROUND STORAGE TANK <br />FACUTY EMPLOYEE TRAINING CERTIFICATE (Page 1 of 1) <br />1• FACILITY INFORMATION <br />Business Name (Same as Facility Name or DBA -going Business As) <br />�/ raw I�.� C RSjlq <br />aus,h—osS Site o �7 �/` 1(9 <br />1 Cityf ZIP Code <br />II. <br />DESIGNATED- UNDERGROUND STORAGE TANK OPERATOR INFORMATION v <br />Name t ❑,e9ignated UST Operator Providing the Tfarn,ng (print as shown on the ICC Certification.l <br />Mailings Address <br />PO Box 933, West Sacramento, Ca 95605 Phone # <br />ICC C reification # 916) 371.2380 <br />% ICC Certification Expiration parte <br />n F o <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 />E] 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 />Name of Individual(s) Trained <br />U _ S '- <br />�G! _ <br />Initial Training Date <br />Date of Assuming <br />Responsibility as a <br />Facility Employee <br />.7 <br />1V. 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, 1 Nvision 3, Chapter 16 Se tion 2715(c) and all the information provided herein is accurate. <br />Training asignated W Oper or Si iature — - <br />Date of Trai ng <br />CERS = Caoiorr :., Environmental Reporting System, ID = Identification, ICC = intemational Code Council, UST =Underground Storage Tank <br />I <br />