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UNDERGROUND STORAGE TANK <br /> FACILITY EMPLOYEE TRAINING CERTIFICATE (Paget of t( <br /> I. FACILITY INFORMATION <br /> Business Na gme as Fath ame oOr BA-Doing Business As) C I <br /> Business s Ci IP�P�/ �lc1Cl n JJ <br /> It. DESIGNATED UNDERGR UND STORAGE TANK OPERATOR INFORMA ION <br /> Name of Designated UST Operator Promoting the Trzining(Print as shown on the ICC CertKroationJ <br /> Edward Stearns <br /> Mailing Address Phone# <br /> 416 2nd Street Galt CA 95632 209 744-0112 <br /> ICC Cenifwtlon if ICC Certification Expiration Dale <br /> 8883080-UC 2/23/2020 <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"tried <br /> before performing facility employee dudes. <br /> Ej Check this box if a list of the lndividual(s)tralnedIs appended to this form. The appendedliso site minimum,must contain <br /> all of the information In this section. <br /> Date of Assuming <br /> Name of Individual(s)Trained Initial Training Date Responsibility as a <br /> Facility Employee <br /> ( t l <br /> / X00 7 <br /> / 4 a0 07 <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,Division 3,Chapter 16,Section 2715(c)and all the information provided herein Is accurate. <br /> Trzining Designated UST Operator Signature Dete of Training <br /> (FRS=CaewnisE mrxmiW Reporting D her,ID=1tlaiAfiration.ICC=InkersGmal Catle Cpax],UBT=UMagmM saage Ts,, <br />