Laserfiche WebLink
UNDERGROUND STORAGE TANK <br />FACILITY EMPLOYEE TRAINING CERTIFICATE (Page 1 of 1) <br />1. FACILITY INFORMATION <br />Business Name (Same as Facility Name or DBA -Doing Business As) <br />SupervaluCEIRS ID <br />Business Site Address 10181455 <br />1990 Piccoli Road City ZIP Code <br />Stockton 95215 <br />IL DESIGNATED UNDERGROUND STORAGE TANK OPERATOR IIVFORMATIDN <br />Name of Designated UST Operator Providing the Training (Prirrf as shown on the 1CC Certificatipn.j <br />Erik Brown <br />Mailing Address <br />1990 Piccoli Road, Stockton Phone # <br />ICC Certification u (209} 931-7438 <br />$$$3731 ICC Certification Expiration Date <br />Ill. FACILITY EMPLOYEE INFORMATION <br />1/3/2020 <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 />Check this box if a list of the individual(s) trained is appended to this form <br />all of the information in this section. . the appended list, of a minimum, must contain <br />Name of Individual(s) Trained <br />Keith Sample <br />Initial Training Date <br />9/16/2019 <br />Date of Assuming <br />Responsibility as a <br />Facility Employee <br />9/17/2019 <br />IV. CERTIFICATION 13Y DESIGNATED UST OPERATOR CONDUCTING THIS TRAINING <br />The facility employees listed above have completed the required training in accordance with Callfomia Code of Regulations, <br />Title 23, Division 3, Chapter 16, Section 2715(c) and all the information provided herein is accurate. <br />TraDasi nate UST Operator Signature <br />Date of Training <br />9/16/2019 <br />CERS = Callfomia Environmental Reporting System, ID = Identification, ICC = International Code Council, UST = Underground Storage Tank <br />UN -112 www.unidocs.org <br />111 - Rev. 101Q1118 <br />