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���aQ.P ort <br /> �iipo be d�. <br /> F_ t' <br /> 'SR:_ <br /> Mt <br /> tef: _ <br /> Appendix X11 <br /> Underground Storage Tank a of <br /> Underg Certificate (Pact � <br /> Facility Emp/oYee Training o <br /> t FP <br /> _L FAcILITyIIWFORIMATION CERS ID <br /> Doing Business As) <br /> Business Name(S em asFaci/ity/Vame orOBA U <br /> r" �/ �'Yi - ZIP Code <br /> i city_ <br /> Business Site Address <br /> [_ 1 DESIGNATED UNDERGROUND STORAGE TANK OPERAT014 INFORMATION <br /> Marne of Designate ud ST Operator Providing Training (Print as shown on the /CC Certification) <br /> Ian Hall # <br /> a Phone <br /> g Address 9258649384 <br /> FaI Wield CA Home Office <br /> ICC Certification# I Certification Expiration Date �J S <br /> 5311539-UC 1110912025 <br /> IIL FA CILITY EMPL 0 YEE INFORMA TION <br /> Individuals assuming the duties of the facility employee before October 13, 2018 must be trained �" I <br /> Within 30 days ofperforming 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 /> Check this box ifa/ist ofthe individua/�sJ trained is appended to this form. 7-he appended list at a <br /> \ rrirninam,must contain all of the information in this section. <br /> Name oflndividual(s) Trained Initial TrainingDate Date of Assuming <br /> Responsibility as a Facility, <br /> ^ EmpllOy�ee <br /> 7p o r)', + .?.3 <br /> z �> <br /> L 1' OUT <br /> lV, r <br /> FERTIFICAT jON BY <br /> The facility ern DESIG u PM <br />-alifornia ployees listed NATED UST ppERA TOR or bode of above have cc. alvt <br /> oration provide egulations� Title mpleted CONDUCTING TIHIS—TiPM <br /> herein is 23, Division 3 the requihed RAINING nM <br /> pining Designated UST accurate. trainin <br />_ US S ' Chapter 1Ei, Section 2 In ac�cordan�e � pM <br /> ature �15(c�� and all the <br /> PM <br />-.Dalifor ' Date tiN1 <br /> UST:Ala Environmental Re °f Tr inin M <br /> Fortin F <br /> ground stor � O <br /> age tank g System ID � Ide <br /> ntifiC Z atiorl, ICC In <br /> ternati()nal COde <br />