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DISPENSING PROPANE SAFELY Check @ Applicable ❑ Dispenser Operator <br />TRAINING CERTIFICATIONS Training Certifications ❑ Cylinder Exchange <br />Customer Training Agreements and Training Instructions for Dispenser Operator's ! Cylinder <br />Exchange Personnel 1 Customer's Employees 1 Agents <br />SHEET 2 OF 2 <br />This sheet must accompany SHEET 1 when more than three Employees 1 Agents are trained. <br />CUSTOMER 1 O1SREKaER 0PER ATOR NAME i'CU$TOMER'I DATE <br />-17 <br />/J(7 W. &may /z <br />ZIP <br />Additional Employees 1 Agents Trained (Include Name, Signature, Date, and Title) <br />CERTIFICATION BY CUSTOMER'S PERSONNEL OF RECEIPT OF TRAINING <br />BY SIGNING BELOW, EACH UNDERSIGNED EMPLOYEE / AGENT OF THE ABOVE NAMED CUSTOMER CERTIFIES THAT HE 1 SHE <br />HAS RECEIVED TRAINING FROM THE COMPANY INSTRUCTOR IN THE PROPER PROCEDURES TO USE, INSPECT, FILL, HANDLE, <br />CONNECT, OPERATE, STORE AND/OR TRANSPORT LP -GAS AND LP -GAS CONTAINERS, AND THAT HE / SHE UNDERSTANDS ALL <br />INSTRUCTIONS INCLUDING EMERGENCY AND FIRST AID PROCEDURES: <br />NAME <br />SIGNATURE AND DATE <br />TITLE <br />4. Cii r <br />& � f V i (n w► fl <br />�-� � � <br />6. <br />7. <br />s. <br />9. <br />lo- <br />ll. <br />12. <br />13. <br />14. <br />is, <br />16. <br />17. <br />18. <br />19- <br />24 - <br />DISTRIBUTION: WHITE or ORIGINAL — SUBURBAN YELLOW or COPY — CUSTOMER SHEET 2 of 2 rtam 1519344 SAF 5120-0713 <br />