Laserfiche WebLink
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 /> Quik Stop Market# 10180893 <br /> Business Site Address City ZIP Code <br /> 3555 W. Hammer Lane Stockton 95219 <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 /> Anthony Reyes <br /> Mailing Address Phone# <br /> P.O Box1025, West Sacramento, CA, 95691 (916) 372-1888 <br /> ICC Certification# ICC Certification Expiration Date <br /> 8293772 11/20/2021 <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 <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 /> Li Check this box if a list of the individual(s)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 /> Li <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 provided herein is accurate. <br /> Tra ing Designated UOperator Signature Date of Training <br /> 4/26/2021 <br /> (F""3 <br /> CERS=Calfomia Fsaironmental Reporting System,ID=Identillication,ICC=International Cade Cound,UST=Underground Storage Tank <br />