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t <br /> UNDERGROUND STORAGE TANK j <br /> FACILITY EMPLOYEE TRAINING CERTIFICATE (Page1 oft) � <br /> 1. FACILITY INFORMATION <br /> Business Name (Sema as Pac!/!ty Name or oBA-�otng ausfness As) CEF25 tD <br /> H &� 10181511 <br /> Business Ile Address ZIP Code <br /> city 95820 <br /> 2501 E. Jackson <br /> saaian <br /> II. DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br /> Nahme of esignated UST Operator roWding the Training (Pdnt as shown a» the ICC CertfRcaG'on.j <br /> Karen pt Arnaiz Pone # <br /> Malting Address 209 518-4836 <br /> P .O Box 162 Lodi CA. 95241 ICC Certification Exp niton i)ate i <br /> ICC Certificauon 8032295 2/3/2021 <br /> 111. FACILI'T'Y EMPLOYEE INFORMATION <br /> individuals assuming the duties of the facility employee before October 13, 2418 must be trained within 30 days of performing i <br /> facility employee duties. Individuals assuming the duties of the facility employee on and atter October 13, 2018 must betralned <br /> before performing facility employee dutiess <br /> i <br /> t Check this box Ifft list 01I individuai(s) trained is appended to this form* rho appended i 4 ata minimum, must contain <br /> ail of the information in this section <br /> 10 <br /> Date of Assuming <br /> Name of Individual(s) Trained Initial Training Date ResponsibilIEy as a <br /> Facility Employee <br /> S41 1140 h ,dol � of <br /> 2o% 0 <br /> � s <br /> © $ <br /> N. CERTIFICATION BY DESIGNATED UST OPERATOR CONDUCTING THIS TRAINING <br /> The facility employees Itsted above have completed the required training In accordance with California Code of Regulations, <br /> 2TIffe 23, Divi Ion 3, Chapter 16, Section 271d(c) and all the Information provided herein is accurate. <br /> ng Hated UST p for Sign re Date of Training <br /> Br13r2o19 <br /> caiforntaEnvioynentolRepotIngSystem, toR , ICCptnlergatirxraiCadeCoin. usr= UndergroundStorageTank <br />