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Appendix XII <br /> I, utility pm IO ndergrbund Storage Tank <br /> FACILITY p Yee Training Certificate (Page 1 of 1) <br /> Buslness me INFpRMATION <br /> 7.Elev1_.z_415 (Same as Facilit <br /> 31 Y Name or DBA -Doing Business As) <br /> Business Site9 NoCERS ID <br /> Address <br /> 337 10899427 <br /> rth Tracy Boulevard City <br /> II. ZIP Code <br /> DESIGNATED Tracy 195376 <br /> UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br /> Name °f Designated UST Operator Provide <br /> Sergio Tejeda ng Training (Print as shown on the ICC Certification) <br /> Marling Address <br /> 25971 Towne Centre Dr. South, Foothill Ranch, Phone# <br /> ICC Certification �$ CA 92610 (949)460-5200 <br /> 10216436 ICC Certification Expiration Date <br /> - 512512024 <br /> III• FACILITY EMPLOYEE INFORMATION <br /> Individuals assume)geth 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 /> IX I Check this box if a list of the individual(s) 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 /> See Appended List <br /> Iv. C <br /> ERTtFICATION BY DESIGNATE© �ST t�PEBATaR CONDUCTING THIS TRAINING th <br /> Fisted above have completed the required training In ac and all the <br /> The facility employeesp;vision 3, Chapter 16, Section 2715(c) <br /> California Code of Regulations, Title 23, <br /> information provide herein is ac rate. Date of Training <br /> _ y Operator i n e 041l612024 <br /> Train g Designated UST <br /> _---- - <br /> taI Reporting System, ID = Identification, ICC = International Code <br /> California Environrnen e tank <br /> - CERS ' round storag 7-11-4 <br /> Council, UST = Underg <br />