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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 /> Quik Stop Market # 1 <br /> Business Site Address City ZIP Code <br /> 1721 S Cherokee Lane 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 /> Timothy L Culp <br /> Mailing Address Phone # <br /> P . O . Box 1025 , West Sacramento , CA 95691 916 37Itrained <br /> ICC Certification # ICC Certification Expiration Date <br /> 8255764 1 /4/2020 <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 <br /> facility employee duties . Individuals assuming the duties of the facility employee on and after October 13, 2018 mus <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 Individual (s ) Trained Initial Training Date Responsibility as a <br /> Facility Employee <br /> UST OPERATOR CONDUCTING THIS TRAINING <br /> IV . CERTIFICATION BY DESIGNATED <br /> trainingin <br /> The facility employees listed a S av2715impleted the required(c) and all the information p ovided herein is acrate. <br /> uratlCode of Regulations , <br /> efornia <br /> Title 23 , Divis10n ,3, Chapter 16 , gcti <br /> Date of Training <br /> `'� Trainin De ig ted ST eratgh re <br /> / l <br /> CERS = Ca omia Environmental Reporting System, I = Identification, ICC = International Code Council, UST = Underground Storage Tank <br />