Laserfiche WebLink
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 # jCvI <br /> Business Site Address City t3 ZIP CQdeya <br /> 07 2 . CaMEnv�v L l) <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 /> Harold Largo Jr <br /> Mailing Address Phone # <br /> ICC Certification # TcC Certification Expiration Dale <br /> 8293993 9/30/2020 <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 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 /> Date of Assuming <br /> Name of Individual (s) Trained Initial Training Date Responsibility as a <br /> Facility Employee <br /> , i KA (� ' � �a " ISI " IL — � <br /> I IVr ,< I __\ <br /> �' - �l ri <br /> L U 119 <br /> ENVIR <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 31 Chapter 16, Section 2715(c) and all the information provided herein is accurate. <br /> Date of Training <br /> �3 Training Designd UD <br /> ate <br /> ST Operator Signature <br /> CERS = Califomia Environmental Reporting System, ID = Identification, ICC = Intern " ode Council, UST = Underground Storage Tank <br />