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UNDERGR <br /> OUND STORAGE TANK TE (page t of 1) <br /> FACILITY EMPLOYEE TRAININN nFICAORMATION CERS ID <br /> I FACIL U Z <br /> Zip Code <br /> Narr]e o�Da-0cing Business As) <br /> jusihess Nam Same as Facility (,e City���Td <br /> L � SII,re5''TOR INFORMATION <br /> Business Site Add 157 re � OPERA Chap <br /> �( r� STORAGE TANK <br /> DESIGNATED UNDERGROUND <br /> II. the Training(Print as shown on the ICC Certification.) phone# <br /> Marne of Designated UST operator Providing 209 744-0112 agate <br /> Edward Stearns <br /> Ma'i'n9 Address iration Date 2J2312Q2Q <br /> 416 2nd Street Galt CA 95632 ICC Certification Exp egate <br /> lcc Certification# 88g3p80-UC s of performing <br /> III. FACILITY EMPLOYEE INFORMATION Sect <br /> 2018 must be trained <br /> to ee before October 13, 2018 onuand after Octobter113,0 ay <br /> the duties of the facility employee Individuals assuming the duties of the facility employee must contain <br /> facility employee duties.Individuals assuming <br /> before performing facility employee duties. ended list,at a minimum, <br /> p 9 The app <br /> Check this box if a list of the individual(s)trained is appended to this form. <br /> ❑ Date of Assuming <br /> all of the information in this section. Date Responsibility as a <br /> Name of Individual(s)Trained <br /> Initial Training Facility Employee ve <br /> Z _Z cc Z t -2c< -Z 2 <br /> z 2Z t_ 24 —2Z <br /> 4?�c� " ? -Z <br /> tJ�cr41, <br /> z <br /> Aj <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 31 Chapter 16, Section 2715(c)and all the information provided herein is accurate. <br /> Training Designated UST Operator Signaturett Date of Training <br /> 6ff ),`9 —23 <br /> =California Environmental Reporting System,ID=Identification,ICC=Intemational Code Council,UST=Underground Storage Tank <br />