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a <br />v <br />UNDERGROUND; STORAGE GE TANK <br />F CIL'ITY.E PLOYEE`T ,.. II. I . G CERTIFICATE (Page 1 of 1) <br />1. FACILITY INFORMATION <br />Business Nam (Same as Facility Name qr DBA -Doing Business As) <br />CER 3 IQ <br />>k i5\3 4>3 <br />Business ite d / �j <br />city <br />II. DIESIGN TED UND" E*kd]kQUN.D:.STOP.AGE TANK OPE I RATOR INFORMATION <br />Name of Designs us p ator roviding the Training (Print as shown on the ICC Certification.) <br />44 <br />Mailing Addre s <br />Phone # <br />ICC Certification # � p� f� ICG Certification Expiry ion FDate_ <br />.., <br />FACILITY EM0.0" ` NFAR ATI N , . <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(d) trained Is appended to this form. The appended list, at a minimum, must contain <br />ail of the Information In this section. <br />Name of Individual(s) Trained <br />Initial Training Date <br />Date of Assuming <br />Responsibility as a <br />Facility Employee j <br />12-816 <br />2 cc/ <br />6E TIFIC TIt�N'DY.D ` IGR `tED:E15T l3"'K11"INDUCTIPIG 1ST WING <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 2T15(c) and all the Information provided herein is accurate. <br />Training Designated UST Oper r Signa <br />Date of Training <br />�� <br />CERS = Wilbmia EnvironmeritEd Reporting System, ID = Iden0cation, ICC = trilemadonal Code Council, UST = Undergnxind Sbrage Tark <br />