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Appendix XII Underground Storage Tank Facility Employee Training Certificate (Page 1 of 1) I. FACILITY INFORMATION Business Name (Same as Facility Name or DBA -Doing Business As) CERS ID Rebel #0376 (Tracy Shell) ��1 Business Site Address City ZIP Code 3725 N. Tracy Blvd. Tracy 95304 II. DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION Name of Designated UST Operator Providing Training (Print as shown on the ICC Certification) Marcus Villabrille Mailing Address Phone # 11000 N. Mopac Expwy #500, Austin, TX 78759 (408) 709-9965 ICC Certification # ICC Certification Expiration Date 10319923 July 7, 2025 III. FACILITY EMPLOYEE INFORMATION Individuals assuming the duties of the facility employee before October 13, 2018 must be trained within 30 days of performing facility employee duties. Individuals assuming the duties of the facility employee on and after October 13, 2018 must be trained before performing facility employee duties. ❑ 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 information in this section. Date of Assuming Name of Individual(s) Trained Initial Training Date Responsibility as a Facility _ Employee April Pruitt 109105/23 09/05/23 Kadie Wales 11/28/23 11/28/23 Francisco Alfaro 09/05/23 09/05/23 Dominique James 12/27/23 12/27/23 Mitchell Schwartz 12/27/23 12/27/23 IV. CERTIFICATION BY DESIGNATED UST OPERATOR CONDUCTING THIS TRAINING The facility employees listed above have completed the required training in accordance with California Code of Regulations, Title 23, Division 3, Chapter 16, Section 2715(c) and all the information provide herein is accurate. Trai ing Designated ST O er r Signature Date of Training CERS = California Environmental Reporting System, ID = Identification, ICC = International Code Council, UST = Underground storage tank