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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 /> Quick Stop Market # <br /> Business Site Address City �� ZIP Cgde� <br /> Il. DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br /> Name of Designated UST Operator Providing the Training(Pmt as shown on rhe 1CC Certification.) <br /> Harold Largo Jr <br /> Mai)ing Address Phone# <br /> ICC Certification# ICC Certification Expiration Date <br /> 8293993 913012020 <br /> III. FACILITY EMPLOYEE INFORMATION <br /> Individuals assuming the duties of the facility employee before October 13,2018 must be trainee!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 list of the individualls)trained is appended to this form. The appended list,ata 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 /> kA <br /> I <br /> V-1 LA SG n�1r1v l I L <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 Signature Date of Training �^ <br /> CERS=California Erwironmental Reporting System,ID=Identftatbtn ICC=Intern ode Council,LIST=Underground Storage Tank <br />