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UNDERGROUND STORAGE TANK <br /> FACILITY EMPLOYEE TRAINING CERTIFICATE (Page 1 of 1) <br /> I. FACILITY INFORMATION <br /> Business Name(Same as Facility Name or DBA-Doing Business As.) CERS ID <br /> Sutter Health Tracy Community Hospital 10397599 <br /> Business Site Address City ZIP Code <br /> 1420 N. Tracy Blvd. Trac 95376 <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 /> Isaac Anderson <br /> Mailing Address Phone# <br /> P.O. Box 4208 209 532 - 7320 Ext. <br /> ICC Certification# ICC Certification Expiration Date <br /> 8146912 09/10/22 <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 facility <br /> employee duties. Individuals assuming the duties of the facility employee on and after October 13,2018 must be trained before performing <br /> facility employee duties. <br /> Check this box if a list of the individual(s)trained is appended to this form. The appended list at a minimum must contain all of the <br /> information in this section. <br /> Initial Training Date Date of Assuming <br /> Name of Individual(s)Trained Responsibility as a <br /> Facility Employee <br /> Jason Simmons 01/14/14 2014 <br /> Brent Matteroli 05/07/18 2018 <br /> James Rinaldo 02/22/18 2018 <br /> Ariana Fregoso 06/05/05 2005 <br /> Blair Abrams 03/15/12 2012 <br /> Kenny Jones 02/24/20 2020 <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 provide herein is accurate. <br /> Training Designated UST Operator Signature Date of Training <br /> 11/17/21 <br /> CERS=California Environmental Reporting Systems,ID=Identification,ICC=International Code Council,UST=Underground storage tank <br />