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UNDERGROUND STORAGE T.ANK <br /> FACILITY EMPLOYEE TRAINING CERTIFICATE (Page 1 of f) <br /> I. FACILITY INFORMATION <br /> Business Name(same as Facility lame or❑BA-Doing Business AS) CERS ID <br /> W. Charter 76 10915954 <br /> Business Site Address City ZIP Code <br /> 1720 South Fresno Street _ Stockton 195206 <br /> II. DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br /> Name of Designated UST Operator Providing the Training(Print as shown on the fCC CerlWcation.) <br /> Curtis Carpenter <br /> Mailing Address Phone# <br /> 680 Quinn Ave. San Jose, CA 95122 408 971-2445 <br /> ICC Certification# ICC Certification Expiration Dale <br /> 8167865 712912426 <br /> Ill. 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 employee on and after October 13.2018 must be trained <br /> before performing facility employee duties. <br /> ❑ Check this box if a list of the individual(s)trained is appended to this form. The appended fist at a minimum,must contain <br /> all of the information in this section. <br /> Date of Assuming <br /> Name of Individuals)Trained Initial Training Date Responsibility as a <br /> Facility Employee <br /> Ali Mohamed 317/2023 3/7/2023 <br /> f� <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 2715(c)and all the information p ded he is accurate. <br /> Training Designated UST Operator Signature Date of Training <br /> CERS=California Environmental Reporting System,ID=Identification,ICC=Irternatioml Cade Council,UST=Underground Storage Tank <br />