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Appendix X11 <br /> Underground Storage Tannic ; <br /> Facility Employee Training Certificate (Page I of t) <br /> I. FACILITYfNFO' RM TION <br /> Businm Name (Bance as FacAVy Nam or DBA -DoOg Business As) CERS ID <br /> UPS G 1015505 <br /> Business Site Address T CHY ZIP Code <br /> 1532 Broadway Stockton 9 206 <br /> li. DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br /> Larne of Designated UST Operator Providing Training (Print a hown on the ICC Certification) <br /> Corey Pereira <br /> i Mailing Address phone # <br /> P,0 Box 361 San Lea ndr. Ca, 94677 <br /> ICC Certification # 6C Certification ExpiratGon Dake <br /> 590517 07-27-2022 <br /> III. FACILITY EMPLOYEE INFORMATION _...._.. w, <br /> Individuals assuming the duties of the facility empkyyee before October 13. 2018 must betrained <br /> within 30 plays 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)ndividuai(s) trained is appended to this form. The appended list at a <br /> rr niffwrm must contain a1J of The information in this section. <br /> Date of Assuming <br /> Name of Individual(s) Trained irwibal Training Date Responsibility as a Facility <br /> -Emptoyee <br /> 1 . CERTIFICATION BY DESI.GNATED UST OPERATOR CONDUCTING THIS TRAINING <br /> The facffity employees listed above have completed the required training to accordance wfth <br /> Califomia Code of Regulations, Tide 23, Division 3, Chapter 16, Section 2716(c) and all the- � <br /> Information provids herein is accurate. j <br /> ` <br /> Training Designated TSignature" Date of Training <br /> � `.- 109-19-2021 <br /> ERS = Carifomia Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council, UST y Underground storage tank <br />