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UNDERGROUND STORAGE TANK <br /> FACILITY EMPLOYEE TRAINING CERTIFICATE ( Page 1 of 1 ) <br /> I . FACILITY INFORMATION <br /> Business Name (Sande as Facility Name or DBA -Doing Business As) CERS ID <br /> Quick Stop Market # 39 10180797 <br /> Business Site Address City 21P Code <br /> 2285 East Fremont Street Stockton 95205 <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 /> Curtis Carpenter <br /> Mailing Address Phone # <br /> P . O . Box 1025 W . Sacramento , CA . 95691 916 372 - 1888 <br /> ICC Certification # ICC Certification Expiration Date <br /> 8167865 10/26/2022 <br /> III . FACILITY EMPLOYEE INFORMATION <br /> Individuals assuming the duties of the facility employee before October 13 , 2018 must be trainld 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 box if a list of the individuals) trained is appended to this form. The appended list, at a minimum, must contain <br /> all of the inforgtation in this section . <br /> Date of Assuming <br /> Name of Individual( s ) Trained Initial Training Date Responsibility as a <br /> j Facility Employee <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 ) an all the infor n provided herein is accurate . <br /> Training Designated UST Operator Signature DateTraining <br /> n4 Z <br /> CERS = California Erivironmental ReWling System , ID = Iden6fxatlon , ICC = International Cade Council, UST = Underground Storage Tank <br />