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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 /> IF so <br /> Main Street Fuel Circle K 10181307 <br /> Business Site Address City ZIP Code <br /> 419 S . Main Manteca 95337 <br /> Il . DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br /> Name of Designated UST Operator Providing the Training (Print as shown on the ICC Certification.) <br /> Karen R Arnaiz <br /> Mailing Address Phone # <br /> P . O Box 162 Lodi , CA, 95241 209 5184836 <br /> ICC Certification # ICC Certification Expiration Date <br /> 8032295 2/3/2021 <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 /> o Check this box if a list of the Individuals) 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 /> i <br /> I <br /> i <br /> r <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 2716(c) and all the Information provided herein Is accurate. <br /> Training Designated US perator Si to Date of Training <br /> 1 /8/2020 <br /> i' <br /> CERS = CaKomia EnW nr>ental Reporting System, ID = Identificatidn, l = International Code Council, UST = Underground Storage Tank <br /> t <br /> i' <br /> I' <br />