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255 E. Harney Ln, Lodi, Ca 95240 PR0537549 <br /> 06/21/2021 Program: UST <br /> PHOTO 6: <br /> Trainin certificate is incom lete <br /> I - <br /> UNDERGROUND STORAGETANK <br /> FACILITY EMPLOYEE TRAINING CERTIFICATE IPage t m_ n <br /> euelneee Name(Same as Facil or <br /> Nem- I. FACILITY INFORMATION CD <br /> m' D -Doing Busln-ss As) N <br /> euei a Site AE CFRS ID <br /> a <br /> a. ZIP code <br /> Nam.or DII. DESIG <br /> gnaled TED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br /> �9( UST Operator--ding Ute Training(Print as Shown on the ICC Certrf ation.) <br /> Mailing Address r/ <br /> PO Box 933,West Sacramento,C 95605 Pn°ne# <br /> ICC Certification# a 916 371-2380 <br /> CC Certification Expiration Date ^ <br /> / f <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 13,20`18 mustbetramed <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 list,at a minimum,must contain <br /> Ill of the information in this section. <br /> i <br /> Date of Assuming <br /> Name of Individual(s)Trained Initial Training Date Responsibility as a <br /> Facility Employee <br /> uv� cl 5 Irl/ <br /> wcf., ( Sly 1, <br /> <✓ SI <br /> 1p'zq✓"4e" <br /> hV'A eV S1� ° / <br /> n .a,K�<V <br /> IV. CERTIFICATION BY DESIGNATED UST OPERATOR CONDUCTING THIS TRAINING <br /> The facility employees listed above have completed the required training in accordance with Callfornla Code of Regulations, <br /> Title 23,Division 3,Chapter 16 a tion 2715(c)and all the information provided herein is accurate. <br /> Date of T7n!, <br /> Training Designated 9T Oper or Si ature <br /> IF I <br /> �i <br /> CERS=California Environrllental Reporting System,ID=Identification,ICC=Intemabonal Cade C—CA UST=Underground Slcl WTwk <br /> VICKY VANG-LEE, EHS Page 6 of 6 <br />