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UNDERGROUND STORAGE TANK <br />FACILITY EMPLOYEE TRAINING CERTIFICATE (Page 1 of 1) <br />I. FACILITY INFORMATION <br />Business Name (Same as Facility Name or DBA-Doing Business As) CERS ID <br />Costco Wholesale - LODI - 1091 10146151 <br />Business Site Address <br />2680 Reynolds Ranch Pkwy <br />City <br />Lodi <br />ZIP Code <br />95240 <br />II. DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br />Name of Designated UST Operator Providing the Training (Print as shown on the ICC Certification.) <br />Michael Moore <br />Mailing Address <br />25971 Towne Centre Dr. South Foothill Ranch CA 92610 <br />Phone # <br />949 460-5200 <br />ICC Certification # <br />9495322 <br />ICC Certification Expiration Date <br />1 12/17/2021 <br />III. FACILITY EMPLOYEE INFORMATION <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(s) trained is appended to this form. The appended list, at a minimum, must contain <br />all 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 <br />See Appended List <br />IV. CERTIFICATION BY D IG T ST OPERATOR CONDUCTING THIS TRAINING <br />r [{aired training in accordance with Califor Code egulations, <br />The facility employees listed above hav#1cya/// <br />Title 23, Division 3, Chapter 16, Section 2t e i formation provided herein is accurate. <br />n� <br />Training Designated UST Operator Signature V 4--- � pqr711 <br />w <br />CERS = Caidomia Environmental Reporting System, ID = Idenfik;ation, ECC = International Code Council, UST = Underground Storage Tank <br />141e1.91113410M[oil]I <br />