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"o, <br /> het <br /> Epm <br /> P <br /> MOW <br /> W.- <br /> Business Name(Safrm)as FacHity Name or PDA-Doing Business As) CERS 10 <br /> CIO toll, <67 <br /> Business Site Address <br /> City ZIP Code <br /> Olr7- r <br /> T ftikt <br /> �k <br /> Name of Designated UST Operator Providing tfle Training(Print as shown 017 the ICC Certification.) <br /> Harold Largo, Jr <br /> Mailing Address <br /> Phone# <br /> 1625"eachaM Rd, Bakarsfigid. CA 9331A <br /> 9-99 <br /> rc Certification 4 (800) 33T] <br /> fo 1/20 <br /> 829399� ICC Cerfiftation lExplratlon Date 10/01/2022 <br /> Ill <br /> P V <br /> FAT <br /> CILiY' <br /> Y" <br /> Individuals assuming the duties of the cilny employee before October 13,2018 must be trained within 30 days of per orming <br /> facility employee duties.Individuals 2sSluming the duties of the facility employee on and after October 13,2018 must be trained <br /> before performing facility employee du`!es <br /> Check this bar if a fisf of the JndfVid wl(s)trained is appended to Mis form. The appended As4 at a minimum,must -ontain <br /> a//of the informimfion in this section. <br /> Date of Ass rning <br /> N2MO of Indivi I dual(s)Trained Initial Training Date Responslbbil as a <br /> pea i Fdoty 0yee <br /> IZ14 114 <br /> The facility ploy above have completed the required training In accordance with CsIllifornia Code of Regul rtlons, <br /> Title 23, Division 3, Chapter 16,Section#15(c)and all the Information provided herein Is accurate. <br /> [ - 1,71ing Designated UST operator Signature I Date 7of Train <br /> . . <br /> DAM M <br /> U, e c e i v e d Time ff Sep, It, "2021IM �: 0. 6905*nazow C'd'Gmxa-UST- Tark <br /> Ah 1M-Rev, 01"1'18 <br />