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UNDERGROUND STORAGE TANK <br /> FAC IL" EMPLOYEE TRA1NING CERTIFICATE (Page 1 of 11. <br /> I FACILITY INFORMATION <br /> Bu9in $rn9;Sam da l+a�".JPi(y!wTlQ or O <br /> 71 /V ZI 8usrneSS AS) CIERS 10 <br /> Businer <br /> �- 7 <br /> II. t <br /> DESIGN r vi I IJNDGFt RE DUNG STORAGE TA#VK OPERATOR INFORMAjlO�+l <br /> roams Of i7estgr�Htad UST operator Pr I�r9 Che�r�inl�,p fPrm��0:1ishover arra he�Cc Ce+#�cgtraro k <br /> r 111!' I <br /> Mlillhg Address <br /> PO Bax 933, West Bacramen#o, C� 956()5 1 Phone it <br /> tcccert+rcatia (916 7]-238( <br /> �! CC cer!)Mrad"Exp 'on date <br /> SII. FACILITY I`MPtrCYEE INFORMATtO� <br /> Indr iduaIs assuming the duties of the faciltty employee before Octotrer 13, 201a must be trained within 30 days of perfanm <br /> W 1Ity emptoyee duties, Individuals assuming the duties of ute facility MplOyee an and atter October 13,2018 must be hair <br /> before perfOrming facility employee duties. <br /> Chock tris bo)r if a list of the individual(s) trained is appended to this form. The appended III at a rninimum, ,must carpo, <br /> 0 of fhe infwmafion in this secl ori. <br /> I Dots of Assumini <br /> Name of Individual() Trained Initial Training Date Responsibility as <br /> Fackty Smplpyet <br /> 4 <br /> (7 <br /> l <br /> IV. GERTIFICATIUN 13Y DESIGNATED UST OPERATOR CONDUCTING THIS TRAINING <br /> The MOW er�'IPlayO" listed move hive Completed the required training in accordanceC01.0 with California of I:e� <br /> �11�tlor <br /> Title3, D:r+IStori 3, Chapter 1 6, Section 2716(c) and all the information provided herein i5 aCctrrattr. <br /> Date of T m4'�7 <br /> Tfairn Bled 119T OPeraxor Slgnatur <br /> CERS <br /> la �` IC �I•ICG=G�Ccce Ca�md-liST S Tank <br /> 4 i <br />