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UNDERGROUND STORAGE TANK <br />FACILITY EMPLOYEE TRAINING CERTIFICATE (Page 1 of 1) <br />L FACILITY INFORMATION <br />Business Name (Same as Fecilay Name wOBA-Doing Business As) <br />CERS IO <br />S w� Ch fo ion (E <br />Business Sita Address Cdy / ZIP Code <br />.. %. �' CMG �/IC G—OwlI of Si aR <br />II. DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br />Name of DewgnaST Operat/or Pn v ing the Treining (Pn'nf as shown on rhe ICC Certification.) <br />0—/ /1 on <br />n <br />Mailing Address <br />Phone# <br />PO Box 933, West Sacramento, Ca 95605 916 371-2380 <br />ICC CemE®Eon # �� G� 1 1 v ICC CeNfirafton xpaafio Date <br />J h 3 <br />111. 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 <br />employee on and atter October 13, 2018 must be trained <br />before performing facility employee duties. <br />CJS Check this box If list Of individual(s) trained is appended to this form. The appended lisp eta minimum, must contain <br />all of the information in this section. <br />Name of Individuals Trained <br />(I <br />Initial Training Date <br />Date of Assuming <br />Responsibility as a <br />Facility Employee <br />2v <br />0,707 *L3 <br />JAI✓L r <br />.�o <br />® 23 <br />E � <br />g 9vy3 <br />3 wz3 <br />oS 12 <br />Ln <br />II 2 <br />Il 2023 <br />5 <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 3, Chapter 16, Section 2716(c) and all the information <br />provided herein is accurate. <br />Training Designated UST Operator Signature <br />1 Data of Trei ng - <br />CERS=(ABornb Emkaurenpl Repneg System, O=Idmtical ,ICC=NbmaEma Cnle Coaiol UST=untle,'&pnd Snaag.Tek <br />