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UNDERGROUND STORAGE TANK <br /> FACILITY EMPLOYEE TRAININGCERTIFICATE Wage1 oft) <br /> 1. FACILITY INFORMATION <br /> Business Name(Same as Facility Name or DBA-Doing Business As.) CERS ID r. <br /> Harney Lane 76 1 10181595 <br /> Business Site Address City ZIP Code <br /> 2420 141 E. Harney Lane Lodi 195240 <br /> II. DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br /> Name of Designated UST Operator Providing the Training(Print as shown on the ICC Certification.) <br /> Alex A. Jabbari <br /> Mailing Address Phone# <br /> 537 Amherst Court, San Ramon, CA 94583 925 389 - 1262 Ext. <br /> ICC Certification# ICC Certification Expiration Date <br /> 5243897-UC 18/18/24 <br /> III. FACILITY EMPLOYEE INFORMATION <br /> Individuals 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 an 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 /> Gautum Sharma 11/30/22 8/10/21 <br /> Karamjit Kaur 11/30/22 1/27/22 <br /> 1 <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 provide herein is accurate. <br /> Training Designated UST Operator Signature Date of Training <br /> - <br /> 111/30/22 <br /> CERS=California Environmental Reporting Systems,ID=Identification,ICC=International Code Council,UST=Underground storage tank <br />