Laserfiche WebLink
UNDERGROUND STORAGE TANK <br /> FACILITY EMPLOYEE TRAINING CERTIFICATE (Page 1 of 1) <br /> I. FACILITY INFORMATION <br /> Business Name(Same as Facility Name clr DBA-Doing Business As) ERS ID O' ic)� ' <br /> Bu ss City ZiPaode <br /> / II. DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br /> Name of Designated UST er or Pr viding the Training(Print as shown on the ICC Certification.) <br /> Mailing Address •- Phone# <br /> ICC CertjfMavl' � ICC Certification xpirati n Date <br /> C. <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 /> E Check this box if a 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 Individual(s)Trained Initial Training Date Responsibility as a <br /> Facility Employee <br /> S I 3L 6 <br /> 617 <br /> ccl A►6 20 10 I <br /> , I <br /> a / ail <br /> �� IG <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 Design d US perator Si ature Date of Training <br /> CERS=California Environmental Reporting System,ID=Identification,ICC=International Code Council,UST=Underground Storage Tank <br />