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M --I --1 -000 <br /> zT zT = N <br /> U) O iv <br /> --IpU) <br /> CD Cnn Opp <br /> -n 3 (a -5 <br /> O CD N Q 7 <br /> M UNDERGROUND STORAGE TANK - <br /> = FACILITY EMPLOYEE TRAINING CERTIFICATE(Page 1 of 1) 9 CD p <br /> U) '� v <br /> I. FACILITY INFORMATION 0 <br /> -t�j Business Name(Same as Faclidy Name or DBA-Doing Business As) CERS ID CD0 N <br /> Quick Stop Market 0 �p N <br /> City ZIP Code (p W <br /> Business Site Address �SZ < <br /> "sr �'� QI <br /> II. DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION CD <br /> � o m <br /> Name of Designated UST Operator Providing the Training(Print as shown on the!CC Certification.) —n <br /> Harold Largo Jr � CCD <br /> Mailing Address Phone# CD <br /> r-r <br /> 3900 Commerce WayI E <br /> ICC Certification# ICC Certification Expiration Date (Q L 00 <br /> 8293993 9/30/2020 O <br /> III. FACILITY EMPLOYEE INFORMATION (Q (n <br /> Individuals assuming the duties of the facility employee before October 13,2018 must be trained within 30 days of performing O <br /> facility employee duties.Individuals assuming the duties of the facility employee on and after October 13,2018 must be trained N U) <br /> before performing facility employee duties. N G) O <br /> Check this box if a list of the individual(s)trained is appended to this form. The appended list at a minimum,must contain PQ <br /> CD .fir <br /> all of the information in this section. p Q O <br /> -- - Date of Assuming (p <br /> Name of Individual s)Trained Initial Training Date Responsibility as a n <br /> ( Facility Employee W D <br /> LT <br /> v <br /> v <br /> U) <br /> n <br /> v <br /> Z3 <br /> CL <br /> 0 <br /> v <br /> Z <br /> � <br /> I (Z CD <br /> Cn -uo <br /> IV. CERTIFICATION BY DESIGNATED UST OPERATOR CONDUCTING THIS TRAINING D Q <br /> The facility employees listed above have completed the required training in accordance with California Code of Regulations, (zT <br /> Title 23,Division 3,Chapter 16,Section 2715(c)and all the information provided herein is accurate. C <br /> C <br /> Date of Training Z; <br /> Training Designated UST Operator Signature ? p <br /> (D � W <br /> I Repo bn9 System,ID=I tion. Inten-alional Code council,UST=Underg-"Storage Tank <br /> N CERS=Califomta Ernvrvrrtnenta �p <br /> O Z <br /> W <br />