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UNDERGROUND STORAGE TANK <br />FACILITY EMPLOYEE TRAINING CERTIFICATE (Page 1 of 1) <br />!. FACILITY INFORMATION <br />Business Name (Same as Facility Name or DBA -Doing Business As) CERS ID <br />ralD7`%fJGisS_ <br />Business ite Address City <br />! q a - ,, � ZIP Code <br />Il. DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br />Name rof Designated UST Operator Providing the Training (Print as shown on the ICC CeriiFcation.J <br />1-1-1 . D I _ <br />Mailing Address <br />Phone # <br />7 d0�e7 Z%b`57v-�j <br />ICC Certification # ICC Certiflcatian Expiration Date <br />Z �j L Z ` CJ C� �r <br />III. FACILITY EMPLOYEE INFORMATION <br />Individuals assuming the duties of the facility employee before October 13, 2048 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, 2048 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 />Name of Individual(s) Trained <br />l r &r�-r1/ <br />e. <br />Initial Training Date <br />Date of Assuming <br />Responsibility as a <br />Facllity Employee <br />4 /a,. 2 -e, -t <br />IV. CERTIFICATION BY DESIGNATED UST OPERATOR CONDUCTING THIS TRAINING <br />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 />Training Designated UST Operator Signature Date of Training <br />! — <br />Zs- Z <br />CERS = California ErMronmentat Reporting system, l) = Ideritifmfion, ICC = International Code Coundll, UST = Underground Storage Tank <br />