Laserfiche WebLink
UNDERGROUND STORAGE TANK <br /> FACILITY EMPLOYEE TRAINING CERTIFICATE (Page 1 of 1 ) <br /> I . FACILITY INFORMATION <br /> Busine Name (Same as Facility Name or DBA-Doing Business As) CERS I <br /> � p 0L x^ C- 1Q ( �' t3 - <br /> Bus!!'n ss Site ddress Cit <br /> ( � � �� �,Q v1" C� zl� <br /> 110 DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br /> Name of Designated UST Operator Providing the TraininPrint as shown on the ICC Certiflcatlon.) <br /> Mailing Address Phone # <br /> ICC Certification # ICC Certification Expiration Date <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 /> Ei 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 /> tt <br /> Date of Assuming <br /> Name of Individual(s) Trained Initial Training Date Responsibility as a <br /> Facility Employee <br /> h goo, <br /> � v <br /> � 2 � 0 <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 /> Training Designated UST Operator Signa Date of Training <br /> c, <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code Council, UST = Underground Storage Tank <br />