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UNDERGROUND STORAGE TANKMOM <br />FACILITY EMPLOY <br />EE TRAINING CERTIFIGATE (Page 1 aft) <br />Business Name (Same as Fadi !lame or DBA -Dal 9 AACILiTY-INFORMATION <br />Bvslnes <br />U .� C�>�s in <br />Business site Address/ 1U/�lGIS-s✓ <br />1 G Ct✓%) City ZIP Code <br />II• DESIGNATED UNDERGROUND STORAGE TANK OPERATOWINFORMATION <br />Name of Designated UST Operator Providing the Train (Print as shown on the iCC ceriifiratlon,) <br />Maiting Address <br />ICC Certificatio #t < </ <br />-77_5— 30 151 5-z/4- <br />fl' iia ICQ Certification Expiration Dap <br />III. F'ACI'LITY EMPLOYEE INFORMATION -3 <br />Individuals assuming the duties of the facility employee before October 13418 <br />facility employee duties. Individuals assuming the duties of the facility , 2must be trained within 30 days ofsrtvrrrtin <br />before performing facility employee duties. employee on and after October 13, 2018 Must be trained <br />0 Check this box ff a fist of the individual(s) trained is appended to this {orm. The appended fist at a minimum, must contain <br />all of the information in this section. <br />Name of indlvidual(s) Trained Date ofAssu►ning <br />Initial Training fate Responsibility as a <br />Facfl playee <br />rTitlIV. CERTIFICATION BY DESIGNATED:UST OPERATOR CONDUCTING THIS TRAINING <br />e <br />facility a�npipyees listed above have completed the required training in accordance with California Code of Regulations, <br />23, Division 3, Chapter 16, Section 2715(c) and all the information provided herein is accurate. <br />Training Designated UST Opera iorSignature <br />Date of Training <br />ZZ 7 <br />CERS = CaGfamia Enviro -wtg ReMaN system. ID = identification, ICC = kamm onal Code <br />Cwmd UST Underground Storage Tank <br />