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UNDERGROUND STORAGE TANK <br /> FACILITY EMPLOYEE TRAINING CERTIFICATE(Page 1 of 1) <br /> 11. FACILITY INFORMATION <br /> Business Name(Same as Facility Name o DBA Doing Business As) CERS ID <br /> Business site Address City ZIP Code <br /> �- S <br /> II. DESIGNATED UNDERGROUND STORAGE TANK OPERATOR IN RMATION <br /> Name of Designated UST Operator Providing the Training(Print as shown on the ICC Certification.) <br /> Andrew Baptista <br /> Mailing Address Phone <br /> 745 W, North Bear Creek Dr. (209) 947-5675 <br /> ICC Certification# ICC Certification Expiration Date <br /> 81678$4 8/8/2022 <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 /> Ei 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 e=mployee <br /> L—If'j 27-ZO <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 Designated UST Operator Signature Date of Training <br /> CER.S=Camome Erndror martai Romig S1slem ID=edenWicabon,ICC=interriatiord Code Cound.LIST=Unde ywnd storage Tari 111-Rev.10101/18 <br /> UN-112 www.unidws.org <br />