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Received <br /> Appendix XII 3/21/2024 <br /> Underground Storage Tank <br /> Facility Employee Training Certificate (Page 1 of 1) <br /> • <br /> [:�I.: FACFORMATION <br /> Business Name (Same as Facility Name or DBA -Doing Business As) CERS ID <br /> Rebel #0376 (Tracy Shell) 10IN11 <br /> Business Site Address City ZIP Code <br /> 3725 N. Tracy Blvd. (Tracy 195304 <br /> II. DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br /> Name of Designated UST Operator Providing Training (Print as shown on the ICC Certification) <br /> Marcus Villabrille <br /> Mailing Address Phone # <br /> 11000 N. Mopac Expwy#500, Austin, TX 78759 (408) 709-9965 <br /> ICC Certification # ICC Certification Expiration Date <br /> 10319923 July 7, 2025 <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 /> ❑ Check this box if a list of the individuals) trained is appended to this form. The appended list at <br /> • a minimum must contain all of the information in this section. <br /> Date of Assuming <br /> Name of Individual(s) Trained Initial Training Date Responsibility as a Facility <br /> Employee <br /> ��0.� c� c►M Gl 2 ?�7 Z <br /> , I, � <br /> ►� w crams Z � 2-71—Z3 <br /> _ 1 7— - 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 herein is accurate. <br /> Tri "" g� ;.end� er toru� nature Datp of <br /> �Hing <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council, UST = Underground storage tank <br />