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Appendix XII Underground Storage Tank Facility Employee Training Certificate ( Page 1 of 1 ) I . FACILITY INFORMATION r. Business Name ( Same as —ldy Name or DBA - Doing Business . As ) CERS ID Sfeckko 1 At� SF $ 2 IGI �� } : Business Site Address City/I JJ ,, ZIPCode 11 . OESIGNATEIT . UNDERGROUND STORAGE TANII OPERATOR INFORMATION Name of Designated UST Operator Providing Training ( Pent as shown on the ICC Ce - n ) 'cC1ar Q �59r1 Matling Address M "" hone # 45 Iterivm 6, � Ell Uw�� ua .C-A g3W3 805 y "" " I ICC Certifcation . # ICG Certification Expiration Date 525L � R3 UG It to &a ' 22 III . " FACILITY EMPLOYEE INFORMATION : Indwiduals assuming the - es of the . facility employee before October 13 , 2018 musbbe trained within 30 days of performing facility employee duties : Intlividuals assuming the duties of the fac " ity employee on and after October 1 . 3 , 2018 musfbe trained before pertorming facility employee duties . Check thistiox if a J t of the individuals) trained is : appended to . this form . The appended list at a minimum must contain all of the informationin . this section: Date of Assuming Name of Individual ( s ) Trained Initial Training Date Responsibili y as a Facility Employee $ i ' C c �c� reJ . las viucvH a � , zooS Mar 30 � aoO S c 1Ne �kti .t )� 145 � . 2c� zl 14 +, 2U2 IU . 'CERTIFICATION BY : DESIGNATED ' UST OPERATOR CONDUCTING THIS. TRAINING , The facility employeeslisted above have completed the required training in accordance with California Gode - of Regulations , Title 23 , Division 3 , Chaptef 16 , Section 2716 ( c ) and all the . information provide herein is accur Training Desi gnatedU T erat r re DateofTraining CERS = California Environmental Reporting System , ID Identification , ICC = International Code Council , . UST = Underground storage tank