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UNDERGROUND STORAGE TANK <br /> FACILITY EMPLOYEE TRAINING CERTIFICATE (Page If of 1 ) <br /> I . FACILITY INFORMATION <br /> Business Name (Same as Facility Name or DBA-Doing Business As) CERS ID <br /> TW Quick Stop Market # �, L ZIP CQdey <br /> Business Site Address City J� <br /> 07 2 So C4116 III <br /> lit 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 Phone # <br /> Mailing Address <br /> ICC Certification # ICC Certification Expiration Date <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 /> ❑ 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 Individuals) Trained Initial Training Date Responsibility as a <br /> Facility Employee <br /> hay <br /> Or SGvNdhi (v f 1 - \ 9 <br /> VLima LOW <br /> OCT ` " 2019 <br /> ENVIR <br /> SIGNATED UST OPERATOR CONDUCTING THIS TRAINING <br /> IV. CERTIFICATION BY DE <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 /> Training Designated UST Operator Signature <br /> CERS = Califomia Environmental Reporting System, ID = Identification, [CC = Intern ode Council, UST = Underground Storage Tank <br />