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Appendix XII <br /> Underground Storage Tank <br /> Facility Employee Training Certificate (Page 1 of 1) <br /> I. FACILITY INFORMATION <br /> Business Name (Same as Facility Name or DBA -Doing Business As) CERS ID <br /> Ij( S�oG� ?o N 57 ,-- bl 49 37 <br /> Business Site Address City ZIP Code <br /> j_/04/b W675T G /�.��� S �c�c��7o� CK20zf <br /> II. DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br /> Name of Designated UST Operator Providing Training (Print as shown on the ICC Certification) <br /> PNcj� 6 <br /> Mailing Address Phone # <br /> _//06 11v'CAn12 - �� 2� � �s c�� 2d y 73G-�yz <br /> ICC Certification # ICC Certification Expiration Date <br /> 9 cl 7 2-779 - /s=-z� z <br /> III. FACILITY EMPLOYEE INFORMATION <br /> Individuals assuming the duties of the facility employee before October 13, 2018 must be trained <br /> within 30 days of performing facility employee duties. Individuals assuming the duties of the facility <br /> employee on and after October 13, 2018 must be trained before performing facility employee duties. <br /> 0 Check this box if a list of the individual(s) trained is appended to this form. The appended list at <br /> a minimum must contain all of the information in this section. <br /> Date of Assuming <br /> Name of Individual(s) Trained Initial Training Date Responsibility as a Facility <br /> Employee <br /> P � /V Lf, - z &> 1 - 15 - 2 . <br /> 2l (24nN41-A C - 7 - ZL) <br /> v-4 <br /> 0 fnn DZ1 /'/ <br /> �- /c a- <br /> o Ro <br /> -y0A TAAL1 194 K,"�f) - ?3 �?o <br /> & A7 G7' 7 - Z3 - 2 <br /> j'v e V Nc-.�� �' ,ze _ y z _ I Z <br /> IV. CERTIFICATION BY DESIGNATED UST OPERATOR CONDUCTING THIS TRAINING <br /> The facility employees listed above have completed the required training in accordance with <br /> California Code of Regulations, Title 23, Division 3, Chapter 16, Section 2715(c) and all the <br /> information provide herein is accurate. <br /> Trainin Designated UST Operator Signature - Date of Training <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council, UST = Underground storage tank <br />