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UNDERGROUND STORAGE TANK <br /> FACILITY EMPLOYEE TRAINING CERTIFICATE (Page t of ty <br /> I. FACILITY INFORMATION <br /> Business Name Game as Facility Name or DBA-Doing Business As) CERS ID <br /> Adelfos AM PM 10830655 <br /> Business Site Address City ZIPS Code <br /> 3443 Cherokee Road Stockton 95205 <br /> II, DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br /> Name of Designated UST Operator Providing the Training(Print as shown on the 1CC Certification.) <br /> Gabriel Martin <br /> Mailing Address Phone#A <br /> 25971 Towne Centre Dr.South, Foothill Ranch CA 92610 949 460-5200 <br /> =Certification# ECC Geriifrcation Expiration Vate <br /> 8260320 5i512022 <br /> III; FACILITY FMPLiOYEF 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 Individual(s)trained is appended to this form. The appended Ustf 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 uste Responsibility as a <br /> Facility Employee <br /> See Appended List <br /> i <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 Cade of Rvguiations, <br /> Title 23,Division 3,Chapter 16, Section 2715(t)and all the information provided herein Is accurate. <br /> Training designated UST Operator Signature n ,----- r - Date of Training <br /> / E; �'' f✓ 5/24/21 <br /> GER S Caftnia Em*"wital ftmting System,0=MOM§m IGC WMmMbd Gode GwUa UST-ftwqaM SvW Tank <br /> M ISC-3443CHE R <br />