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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 152 <br /> Business Site Address City ZIP Code <br /> 1721 Cherokee Ln _ Lodi 195240 <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 /> 3900 Commerce Dr West Sacramento Ca <br /> ICC Certification # ICC Certification Expiration Date <br /> 8293993 11 /4/2018 <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 /> ST OPERATOR CONDUCTING THIS TRAINING <br /> IV, CERTIFICATION BY DESIGNATED U <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 /> APAL% Date of Training <br /> Joy <br /> Training Designated UST Operator Signature / / / 00 I /D <br /> � v <br /> CERS = Califomia Environmental Reporting System, ID = Identification, ICC = International Code Council, UST = Underground Storage Tank <br />