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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 /> Safeway #2600 <br /> Business Site Address City ZIP Code <br /> 1967 W. 11th St. Tracy 95376 <br /> II , DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br /> Name of Designated UST OperatProviding the Training (Print as shown on the ICC Certification.) <br /> eye'• a . V� <br /> - - <br /> Walling Address Phone # <br /> 680 Quinn Ave . San Jose , Ca 95112 (408 ) 971 - 2445 Ext, <br /> ICC Certification # ICC Certification Expiration Date <br /> 1 S:ee�q UL �'s S <br /> Ill , FACILITY EMPLOYEE INFORMATION <br /> Individuals assuming the duties of the facility employee before October 13, 2018 must be trained within 30 days of performing facility <br /> employee duties. Individuals assuming the duties of the facility employee on and after October 13, 2018 must be trained before performing <br /> facility employee duties . <br /> Check this box if a list of the Individual(s) trained Is appended to this form. The appended list ata minimum must contain all of the <br /> information in this section. <br /> Initial Training Date Date of Assuming <br /> Name of Individual(s) Trained Responsibility as a <br /> Facility Employee <br /> e ( f 3 A) 4 <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 all the information provide herein is accurate . <br /> Training Designated UST Operator Signature Date of Training <br /> i <br /> CERS = California Environmental Reporting Systems, ID = Identification, ICC = International Code Council, UST = Underground storage tank <br />