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<br /> ' 6 Business Na (Same as Fad/V Name or DBA-Doing BusinassAs) CERS ID
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<br /> Nama of Deai ted UST Operator Pr vid n the Training (Pint as shown on the [GO Gertilicadon.) '
<br /> Mailing Address Phone #
<br /> PO Box 933 , West Sacramento , Ca 95605 916 371 -2380
<br /> IGC Cenificatlon 0 ICC Cartificafion Expiration Date
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<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 box Jf a 11st of the individuals) trained is appended to this form. The appended /iso at $ minimum, must eontaln
<br /> all of the information in this sectlon.
<br /> Date of Assuming
<br /> Name of Individual(s) Trained Initial Training Date Responsibility as a
<br /> Facility Employee
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<br /> For
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<br /> Follow
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<br /> Food
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<br /> The facility employees listed above have completed the required training In accordance with California Code of Regulations,
<br /> Tithe 23, Division 3, Cha ter 16, Section 2716(c) and all the Information provided herein is accurate.
<br /> Training DesignatedU Opera r Slghature Date of T7aining
<br /> CERS = CaQfomla FhNronmarMI Reporting System, ID = Identification, ICC = intemationai Code Coundl, UST = Underground Storage Tank
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