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DISPENSING PROPANE SAFELY Check 0 Applicable ❑ Dispenser Operator TRAINING CERTIFICATIONS Training Certifications Cylinder Exchange Customer Training Agreements and Training Instructions for Dispenser Operator's 1 Cylinder Exchange Personnel / Customer's Employees /Agents CUSTOMER, SHEET 1 OF 2 a/T-& (,.2I 'fG' T ADDRESS' tra W - 'Alev y / *z,— ZIP CERTIFICATION BY CUSTOMER'S PERSONNEL / DISPENSER OPERATOR'S PERSONNEL OF RECEIPT OF TRAINING BY SIGNING BELOW, EACH UNDERSIGNED EMPLOYEE 1 AGENT OF THE ABOVE NAMED CUSTOMER CERTIFIES THAT HE 1 SHE HAS RECEIVED TRAINING FROM THE COMPANY INSTRUCTOR IN THE PROPER PROCEDURES TO USE, INSPECT, FILL, HANDLE, CONNECT, OPERATE, STORE AND/OR TRANSPORT LP -GAS AND LP -GAS CONTAINERS, AND THAT HE/SHE UNDERSTANDS ALL INSTRUCTIONS INCLUDING EMERGENCY AND FIRST AID PROCEDURES: NAME SIGNATURE AND DATE TITLE ,. Ar) 4ti 5),r1b, I 6k1a- 91:r4l '. L4�-c a A w- MODULE 8 — Emerging Technologies 3. S L " I �W �1'� �"7 rL For additional Employees f Agents trained (4 through 20), complete the attached SHEET 2 of 2 (see back of document). ENTER TYPE OF DISPENSING - From "Dispensing Propane Safely Training° Diagram (R1, R2, etc.): PERC QPPENSING PROPANE SAFELY TRAINING PERFORMED - Enter a checkmark I1 foLgaeh training module completed ato-RULE 1 — Introduction 96110-L711LE 4 — DOT Cylinders MODULE 7 — Refueling ASME Motor Fuel and RV Tanks �� L`1MODULE 2 — Properties and MODULE 5 — inspecting, Filling, and MODULE 8 — Emerging Technologies Characteristics of Propane Labeling Small Cylinders YELLOW or COPY-- CUSTOMER LE 3 — Dispensing Station ❑MODULE 6-- Refueling, Maintaining, ❑MODULIE S —Retail Cylinder Exchange Equipment and Troubleshooting Forklift Cylinders Operations CUSTOMER 1 DISPENSER OPERATOR ACKNOWLEDGEMENT 1 AGREEMENT CUSTOMER 1 DISPENSER OPERATOR ACKNOWLEDGES AND AGREES TO: • Receipt of the Company's Dispenser Operator Training Package, which includes PERC's "Dispensing Propane Safely" training program. • Use and follow the DISPENSER OPERATOR AND PROPANE CYLINDER EXCHANGE TRAINING INSTRUCTIONS printed on the reverse side of this form as the standard operating procedures for all training. • Be responsible to train, or cause to be trained, all Employees 1 Agents in the proper procedures for handling LP -Gas and LP -Gas containers. • Not allow Employees / Agents to use, inspect, fill, handle, connect, operate, store and/or transport any LP -Gas or LP -Gas container until property trained as outlined in the DISPENSER OPERATOR AND PROPANE CYLINDER EXCHANGE TRAINING INSTRUCTIONS printed on the reverse side of this form- • Contact the Company or other LP -Gas equipment supplier to request materials or assistance, if needed, to conduct all such training- ■ Installation of Signs and Decals in a proper and conspicuous place. • Maintain such Signs and Decals in readable format and to purchase and install, as needed, additional, replacement and/or Spanish language Signs and Decals from the Company or any LP -Gas equipment supplier. UA It TRAINING CERTIFICATION BY SUBURBAN I, THE UNDERSIGNED COMPANY INSTRUCTOR, CERTIFY THAT I PROVIDED TRAINING IN THE PROPER PROCEDURES TO USE, INSPECT, FILL, HANDLE, CONNECT, OPERATE, STORE AND/OR TRANSPORT LP -GAS AND LP - GAS CONTAINERS: COMPANY INSTRUCTORS S1GNAT URE COMPANY FACILITY NAME AND LOCATION NUMBER COMPANY INSTRUCTOR'S N AND TITLE MAMI�L�i �M Y� ��v/ ! ,C COMPANY FACILITY TELEPHONE NUMBER - a Uj y ! V a� o57` OATE 7 7r ^�C DISTRIBUTION: WWTE or ORIGINAL — SUBURBAN YELLOW or COPY-- CUSTOMER SHEET 1 of 2 l:em 1519344 SAF 5120-0773