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RECEIVED ON 09/02/2022 VIA EMAIL <br /> UNDERGROUN') <br /> FACILITY EMPSTORAGE TANK <br /> LOYEE TRAINING CERTIFICATE(Pago 1 of 1) <br /> Business Nam--Nam-- �5'Name or DBA-Da1nNATION <br /> (same asFaci!' i' FACILITY INFORMATION <br /> - g BusJrress AsJ <br /> Busiress Site Address l � V dA CERS!b <br /> �8 Mc V ! city <br /> DESIGNATED ziP code <br /> Name of Designated UST Operator pro d��DgJ iheN� Rg POUND STORAGE nthe 1CC CartJllctr(lon.) <br /> TANK OPERATOR INFORMATION <br /> htalling Address /'/ <br /> ICC Certlfication 4 C3�C /C U y- Phone it <br /> 8 8 4 ICC Certification Expirntion Date <br /> Individuals <br /> Ill. FACILITY EMPLOYE!`INFORMATION <br /> assuming the duties of the faculty©mployea 6©fore October 13,2018 must be trained wi <br /> faculty employee duties.individuals assuming the duties of the facility employee on and after October n 2D18 <br /> before performing facility employee duties thin,2 days of performing <br /> must be trained <br /> ECheck this box if a list of the fndlvldualW trained!s a <br /> all of the lnformatlon In this section. to this form. The appended list,ata minimum,must contain <br /> PAQnded <br /> Name of lndividual(s)Trained <br /> Date of Asauming <br /> � f Initial Tralni g pato Responsl6[uty as a <br /> Fettlfty Employee <br /> v� <br /> !2� zi <br /> v'4)%_N <br /> "2 z z <br /> rv. cERnFr5A710N BY nr=slGNAreD us7 opE�AroR coniDucrlNc rHls 7 <br /> The facility employees listed above have completed tFte re ulred RELINING <br /> 7ttl 23,Division 3,Chapter 1fi,Soctlon 271b(c)and all the Information provided herein is accurate, <br /> 4 training In accordance with California Code of Regulations, <br /> Traf ng Designated UST Aper r sign e <br /> Date of Tralning <br /> CE72S Ca*w'a Erntm Repollt SY -gym ID-1 <br /> ICC Code <br /> C.4 UST SU-age Tank <br />