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UNDERGROUND STORAGE TANK <br /> FACILITY EMPLOYEE TRAINING CERTIFICATE (Page 1 of 1 ) <br /> I . FACILITY INFORMATION <br /> Business lame (Same pjFacffity Name or DBA-Doling Pusiness As) CERS ID <br /> psi S - - <br /> Business Site Addres City ZIP Code <br /> 112 �j U <br /> U . le I <br /> DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br /> ,,Name of Designated UST Operator Providing the Training (Print as shown on the /CC Certification.) <br /> Zane NIMMO <br /> Mailing Address Phone # <br /> 416 2nd Street Galt CA 95632 209 744-0112 <br /> ICC Certification # ICC Certification Expiration Date <br /> 8883064- UC 2/25/2020 <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 individuals) 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 Tr inino Date Responsibility as a <br /> Facility Employee <br /> � { OZ 112 <br /> 7 131 <br /> ct <br /> o <br /> i <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 ail the Information provided herein is accurate. <br /> Training Designated UST Operator Signature 4 Date of T fining <br /> � �� t i ► <br /> CERS = CaBfomia Envlonmerbl Reporting System, ID = Identification, IOC = International Code Council, UST = Underground Storage Tank <br />