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M 0 < � -- - <br /> 0 O = N Sll <br /> O N O v <br /> O Q` = � N � <br /> TI (Q : OCD <br /> O <br /> r— <br /> ° IM 7 0 <br /> o t o 0 <br /> 71 <br /> CD N <br /> M CL criN <br /> = TANK CD <br /> (�UNDERGROUND STORAGE e 1 of til N <br /> CD FACILITY EMPLOYEE TRAINING CERTIFiCA.TE(pa0C- CD D rn <br /> v <br /> 1. FACILITY INFORMATION CERS ID <br /> (Q m <br /> --- Business Name(Same as Facry 'Name or DBAD- oing Business As.} <br /> aterloo liquors zip code v 0 sv <br /> Business Site Address City 3 t? <br /> N <br /> 2512 a waterloo rd. <br /> stacktonc(D o ZL <br /> II. DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION N 00 <br /> Name of Des Hated t75T O N v 70 <br /> °9 perator providin file Training Print as shown on the IGC Certification-) <br /> DAVID TURNER g '�f � o 0- <br /> Mailing Address phone# 2977 Ext a - U)1 t DO N J ST. TULARE CA 93274 559 688-297 m <br /> sll <br /> ICC Certi@cation# n 3 00 <br /> $78$650-UC ICC Certification Expiration Date 00 6 <br /> ii-18-21 0 0 <br /> Ill. FACILITY EMPLOYEE INFORMATION Q N <br /> Individuals assuming the duties of the facilityemployee before October 13,2018 must be trained within 30 days of perform facility 5' <br /> (.0 O () <br /> employee duties. Individuals assuming the duties of the facility employee on and after October 13,2018 must be trained before pe 0 E D <br /> facility employee duties. <br /> Check this box ifa list of the individual(s)trained is a The ended list at a minimum must contain all of itis 0 <br /> appended to this form. PP C: (Q <br /> infomration in this section. C <br /> Date of Assuming <br /> Initial Training Date Responsibility as a (D N <br /> Name of Individual(s)Trained <br /> Facility FmPloyee <br /> SIGN BELOW <br /> 0 0 <br /> CL n <br /> ee 0 Q <br /> .0 /Pig tr L o <br /> 1, civ- N) <br /> U1 <br /> N <br /> O <br /> N <br /> CD <br /> N <br /> I? <br /> CD <br /> CD <br /> Cl) <br /> CD <br /> Cn <br /> !v <br /> 7 <br /> 7 <br /> (Q <br /> Cn <br /> M <br /> O_ <br /> 07 <br /> cc C) :0 <br /> CD C (D <br /> n/• CERTIFICATION BY DESIGNATED UST OPERATOR CONDUCTING THIS TRAINING D o <br /> to ees listed above have completed the required training in accordance with California Code of Regulations, o< ° <br /> The facility er Y <br /> title 23,division 3,chapter 16,section 2715{c)and all the information provide herein is accurate, (D Cn C7 <br /> eratar Signature <br /> Date of Training CL <br /> Designated UST Op 2_5_2020 0 CD <br /> (D <br /> v � N <br /> cc -0 -P, <br /> CD O � <br /> W `G W <br /> OCD <br /> fang Systerns,lD=Id1tiftcafinn,ICC=Interrtnalional Coc a I;�!x A'iS'=Jr..te'o,(r,nd Aor kqe fan r (1)W CERS=Caltlorrra� tt�m(wrlercn <br /> t✓� <br />