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UNDERGROUND STORAGE TANK <br /> FACILITY EMPLOYEE TRAINING CERTIFICATE (Pagel of 1) <br /> I. FACILITY INFORMATION CERS ID y <br /> 13usiness Name(Same ajs�,FaciGfy Name or DBA-Doing Business As) D <br /> bi 1 ft(o CO vv1 City LIP Code <br /> Business Site Add ess 12 <br /> II. DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br /> Name of Designated UST Operator Providing the Training(Print as shown on the 1CC Certiticatron.) <br /> Dave WinklerTPhone# <br /> Mailing Address 209 744-0112 <br /> 416 2nd Street Galt CA 95632 iCC Certification Expiration Date <br /> ICC Certification# 2/23/2020 <br /> 8883059-UC <br /> III, FACILITY EMPLOYEE INFORMATION <br /> Individuals assuming the duties of the facility employee before October 13,2018 must be trained within 30 clays 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 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 /> initial Training Date Responsibility as a <br /> Name of Individual(s)Trained Facility Employee <br /> Pr <br /> S s "LcZ� S S z <br /> S1 -5).'1 <br /> 0-L <br /> S10 — Z <br /> �IV. CERTIFICATION BY DESIGNATED UST OPERATOR CONDUCTING THIS TRAINING _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 /> Date of Training <br /> Trainig De <br /> nsignated UST Operator Signature 7 <br /> CERS=California Environmental Reporting System,ID=Identification,ICC=intemational Code Council,UST=Underground Storage Tank <br />