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UNDERGROUND STORAGE TANK <br /> FACILITY EMPLOYEE TRAINING CERTIFICATE (Page 1 of 1) <br /> I. FACILITY INFORMATION <br /> Business Name(Sema as Facility Name or DBA-Doing Business As) CERS ID <br /> Quik Stop#39 <br /> Business Site Address City ZIP Code <br /> 2285 E. Fremont St. istockton 195205 <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 /> Juan Jauregui <br /> Mailing Address Phone q <br /> P.O.Box 1025 (916) 372-1888 <br /> ICC Certification# ICC Certification Expiration Date <br /> 8473759 8/5/2023 <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 boxlfa 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 /> Date of Assuming <br /> Name of Individuals)Trained Initial Training Date Responsibility as a <br /> Facilhy Employee <br /> _ i <br /> i <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 Desi U O iPature Date of Training 8113/2021 <br /> 1 i• <br /> CERS=Caf nial ReporB System,ID� Ration,ICC=IntemaWnal Code Coif/,UST=Underground Storage Tank <br />