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Appendix XII <br /> 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 /> Costco Wholesale -TRACY-0658 10146285 <br /> Business Site Address City ZIP Code <br /> 3250 W. Grantline Rd Tracy 95377 <br /> II. DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br /> Name of Designated UST Operator Providing Training (Print as shown on the ICC Certification) <br /> Gabriel Martin <br /> Mailing Address Phone # <br /> 25971 Towne Centre Dr. South, Foothill Ranch, CA 92610 (949)460-5200 <br /> ICC Certification # ICC Certification Expiration Date <br /> 8260320 4/26/2024 <br /> III. FACILITY EMPLOYEE INFORMATION <br /> Individuals assuming the duties of the facility employee before October 13, 2018 must be trained <br /> within 30 days of performing facility employee duties. Individuals assuming the duties of the facility <br /> employee on and after October 13, 2018 must be trained 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 <br /> a minimum must contain all of the information in this section. <br /> Date of Assuming <br /> Name of Individual(s) Trained Initial Training Date Responsibility as a Facility <br /> Employee <br /> See Appended List <br /> IV. CERTIFICATION BY DESIGNATED UST OPERATOR CONDUCTING THIS TRAINING <br /> The facility employees listed above have completed the required training in accordance with <br /> California Code of Regulations, Title 23, Division 3, Chapter 16, Section 2715(c) and all the <br /> information provide herein is accurate. <br /> Training Designated UST Operator re n Date of Training <br /> 08/31/2022 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council, UST = Underground storage tank <br /> COSTCO-0658 <br />