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ii UNDERGROUND STORAGE TANK FACILITY EMPLOYEE TRAINING CERTIFICATE (Page 1 of 1 ) if I . FACIL INFORMATION Business Name (same as Facility Name or DBA-Doing Busr ess As.) ; CERS ID - � � Wool Business Site Address - - -�° '— i � J� City ( ZIP o e - II . DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION (i Name of Designated UST Operator Providing the Training (Print as shown on the (CC Certification.) Mailing Address — — j Phone # tIf if ICC Certification # _ ICC Certification Expiration Date If _ III. FACILITY EMPLOYEE INFORMATION Individuals assuming the duties of the facility employee before October 13, 2018 must be trained within 30 days of performing facility employee duties. Individuals assuming the duties of the facility employee on and after October 13, 2018 must be trained before performing j facility employee duties . if it Check this box if a list of the individuals) trained is appended to this form. The appended list ata minimum must contain all of the information in this section. --- ii 2 k i Training Date/ Date of Assuming Name of Individual(s ) Trained Responsibility as a { fit U Facility Employee it 6X If 04 tO t f t�4 L it that moi, 17 if is it i if i it Ififi i IV. CERTIFICATION BY DESIGNATED UST OPERATOR CONDUCTING THIS TRAINING J The facility employees listed above have completed the required training in accordance with California Code of Regulations , i ' ;; title 23, division 3 , chapter 16 , section 2715 (c) and all the information provide herein is accurate. ii it Training Designated UST Operator Signature — Date of Training j 1 , f it CERS = California Environmental Reporting Systems ID - _ . t ,_,_ on, It = rral Code Council, UST = underground storage tank