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I. <br />UNDERGROUND STORAGE TANK <br />FACILITY EMPLOYEE TRAINING CERTIFICATE (Paget of 1) <br />I. FACILITY INFORMATION <br />❑unloose N.. (same a Padaly Nome OrDW Odnp BwMao.-1 <br />Oulok Sto 1)125 <br />CERS ID <br />1018643 <br />Ommose BllO Mdmas - <br />1580 W.Main SI <br />Clry <br />RI on <br />ZW Cees <br />95366 <br />H. DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br />Nm" dOaslpnd" U5f Opomlm PrevNelp Iho Training (Pdnl ns alimsn nn IM ICLCpniFimaen.) <br />Curtis Carpentor <br />mowv Maw <br />P.O. Box 1025 W. Sagramento CA 95691 <br />I PMrlea <br />916 372-1888 <br />allocation bplmeoolo <br />IDO Celllamtlat a 'ICG n n <br />8167865 10/26/2022 <br />If. FACILITY EMPLOYEE INFORMATION <br />Individuals assuming the duties of the facility moployee before October 13, 2016 must be mi within 30 days of pajorming <br />facility employee duties. individuals assuming the duties little facility employee on and alcor Oetobor 13, 2018 must be trained <br />before podormin0 facility employee duties. <br />Chockfhls berll n list of the lndivldualfs) lmined is appended to this form. Tho appondedi/sg of o minirnurrr, muaf confaln <br />all allho inforgraf/mr In thin saellon. <br />Name of ladlvidualis) Trained <br />Initial Training Data <br />Dela of Assuming <br />RaaponslElllryasa <br />Facility Employ" <br />wt Vl1 <br />u13G/1 <br />IV, CERTIFICATION BY DESIGNATED UST OPERATOR CONDUCTING <br />T1119 TRAINING <br />The faclllly employees listed above )lova completed the required training In accordance with California Code of Regulations, <br />Tido 23, Division 3, Chapter 16, Section 2716(c) and all the Infomrallon provided hmcln Is accurate, <br />TraWrp.....Mhad UST Oparelof Slpnallua Daloal TraWng <br />429- 21 <br />Cf]iS • Caam le FinlairuMa Repol6lp Sysalt ID. UncdrMm ICC . IdmsMbml Ca W Cnacl U6'f • Urlrpnavl laaapo To -A <br />