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Appendix XII <br /> Underground Storage Tank <br /> Facility Employee Training Certificate (Page 1 of 1) <br /> I. FACILITY INFORMATION _ <br /> Business Nam (Same as Facility me or DBA -Doing Business As) RS ID <br /> M oualio 1;LAh_t C -Q Vin CERS <br /> Business Site Address City ZIP Code <br /> `fY4_C 95 ,7 -. <br /> II. DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br /> Name of Designa ed UST Operator Providing Training (Print as shown on the ICC Certification) <br /> � <br /> Mailing Address l Phone # <br /> i 0q2y der �� Q� e �vaYk+6i1e ���I <br /> ICC Certification # ICC Certification Expiration Date <br /> 2— u - z- <br /> III. FACILITY EMPLOYEE INFORMATION <br /> Individuals assuming the duties of the facility employee before October 13, 2018 must be trained <br /> within 30 days of performing facility employee duties. Individuals assuming the duties of the facility <br /> employee on and after October 13, 2018 must be trained before performing facility employee duties- <br /> 0 Check this box if a list of the individual(s) trained is appended to this form. The appended list at a <br /> minimum must contain all of the information in this section. <br /> Date of Assuming Responsibility <br /> Name of Individual(s)Trained Initial Training Date as a Facility Employee <br /> 2 3 — — 12- <br /> Q <br /> 1 — "2,. 3, Z <br /> IV. CERTIFICATION BY DESIGNATED UST OPERATOR CONDUCTING THIS TRAINING <br /> The facility employees listed above have completed the required training in accordance with <br /> California Code of Regulations, Title 23, Division 3, Chapter 16, Section 2715(c) and all the <br /> information provide hereilo is accu te. <br /> Training Designated UST O e for i a Date of Training <br /> CERS = California Environmental Reporting System, 1D = Identification, ICC = International Code <br /> Council, UST= Underground storage tank <br />