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Nov. 14. 2018 4:29PM 11 jk- No. 2487 P. 3 <br /> UNDERGROUNDSTORAGE TANK <br /> FACILITY,EMPLOYEE TRAINING CERTIFICATE(Page'of i) <br /> I. FACILITY INF;RMATION. <br /> Buslness Name(Sa asFac Name orDBA-DoIngousingss As CER:SD <br /> rJ <br /> gp'l <br /> low 0 '011'a <br /> Business to Address 7city Gude <br /> fl. DESIGNATED UNDERGROUND STOAAdE7ANK OPERATOR INFORMATION <br /> Name of Designated,61ff CIPefatOT ProA Ing the Tr® (PrYnt as shown on the 160 Ceriftatlon.) <br /> e,/ <br /> Mailing Addres6 tef2 <br /> 2 7,57 ie <br /> ICC Gerlificalion# Itc Carlincallon Expiroon Date <br /> ell <br /> IF-7 LV?7 <br /> Ill. FACILITY EMPLOYEE INFORMATION <br /> Individuals assuming the duties of the facility employee before October 13,2016 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 /> Ei Check this box if a list of the IndIvIdual(s)tralnedIs appended to this form. The appended/Ist,at a minimum,must contain <br /> aft of the information in this section. <br /> Date of Assuming <br /> Name of Individual(&)Trained Initial Training Date Rasponsiblilty as a <br /> Facility Employee <br /> Z A7 <br /> f7 <br /> f\j 0 qnlo <br /> Phil <br /> V�qjrj <br /> HEALTIq -'TAL <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,DIvIaWn 3,Ch *or 16,Sectio 716(c) all the Information provided herein Is accurate. <br /> 1-1-1 � 1 107 11 <br /> Training DognAdd US 0 rat "atur Date of Training <br /> ,16y <br /> V 1 /0- <br /> CERS=Cagamia RepmftSptemiDinkh-Mmbm.ICCftkiemadoralCo&Cas4UST=Lhid&WwO$tmoTat* <br />