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a <br /> UNDERGROUND STORAGE•TANK <br /> IL TY EMPLOYEE TRAINING CERTIFICATE(Page 1,of 1) <br /> L FACILITY INFORMATION' <br /> Buslness N me(Same as FaciZt4y Name or BA-Doing Susi ss As) CERS ID <br /> s ��� l Iv1&.f � <br /> Business Site Address City ZIP Code <br /> YYu w G1n"-NV <br /> U DESIGNATED UNDERGROUND STOKAGE TANK OPERATOR INFORMATION <br /> Name of Designated UST Operator Providing the Training(Print as shown on the/CC Certification.) <br /> Edward Stearns <br /> Mailing Address Phone# <br /> 416 2nd Street Galt CA 95632 209 744-0112 <br /> ICC Certification# ICC Certification Expiration Date <br /> 8883080-UC <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 <br /> facility employee duties.Individuals assuming the duties of the facility employee on and after October 13,2018 must be trained <br /> before performing facility employee duties. <br /> o 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 /> Date of Assuming <br /> Name of Individual(s)Trained Initia�Training�Datee Responsibility as a <br /> Facility Employee <br /> �.�'� � P�� tet^ � •�>- z3 �• �r • Z1 <br /> r — --- .I,I - Z7 <br /> to Wr yo bcy 2-7 <br /> On <br /> IV- I 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 2716(c)and all the information provided herein is accurate. <br /> — Date of Training <br /> Training Designated UST Operator Signature u I r a 1 —73 <br /> Cpm=Cafifomia En oronmeatal Reporting System,ID=Idenlific9tion,ICC=International Code Coundl,UST=Underground Storage Tank <br />