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UNDERGROUND STORAGE TANK <br /> FACILIMUMTY EMPLOYEE TRAINING CERTIFICATE(page 1 of 1) <br /> I• <br /> Nami=_(Same as Facility Name or DBA FACILITY INFORMATION <br /> ing 8usinessAs.J <br /> top Market-Chevron CERS ID <br /> ess Site Address '10186837 <br /> 51 W. Luise Ave city ZIP Code <br /> Manteca <br /> II. DESIGNATED UNDERGROUND STORAI3E TANK OPERATOR INF-ORMATION 95336 <br /> Name of Designated UST Operator Providing the Training(Print as shown on the ICC Ce <br /> lex A. Jartlfication.J <br /> Abbari <br /> Mailing Address <br /> 537 Amherst Court, San Ramon, CA 94583 Phone# <br /> ICC Certification 4; (925)389- 1262 Ext. <br /> 5243897-UIC ICC Certification Expiration Date <br /> 8/18/22 <br /> III. FACILITY EMPLOYEE INFORMATIONIndividuals assuming the duties of the facility employee before October 13,2018 must be trained within 30 days of performing facility <br /> employee duties. Individuals assuming the duties of the facility employee on and after October 13,2018 must be trained before performing <br /> 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 all of the <br /> information In this section. <br /> Initial Training Date Date of Assuming <br /> Name of Individual(s)Trained Responsibility as a <br /> Facility Employee <br /> Ammy Karriboj 12/1/16 12/1/16 <br /> Rajwinder ICaur 5/4/13 5/4/13 <br /> Hari Kamboj 10/1/06 10/1/06 <br /> IV. CERTIFICATION BY DESIGNATED UST OPEIRATOR 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 provide herein is accurate. <br /> Training Designal:ed UST Operator Signature <br /> Date of Training <br /> 10/5/23 <br /> CERS=Califomia Environmental Reporting Systems,IID=Identification,ICC=International Code Council,UST=Underground storage tank t <br />