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UNDERGROUND STORAGE TANK FACILITY EMPLOYEE TRAINING CERTIFICATE (Page 1 of 1 ) i. FACILITY INFORMATION Business Na a (Same as Facility N me or DBA-Doing Business As) CERS ID A M Z41 . Business Site Address City -, ZIP Code lam' (7 (� $Cl/�i /�-u c� �- �' d! 7a II , DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION Name of Designated UST Operator Providing the Training (Print as shown on the ICC Certification) -P�-� ,2r✓� 3 Mailing Addressy i !n Phone # I-qw • It-Ztit � � �f1-�� i 6 ICC Certification # ICC Certification Expiration Date � 2 (2y 2Z- III . FACILITY EMPLOYEE INFORMATION 2ndividuals assuming the duties of the facility employee before October 13, 2018 must be trained within 30 days of performing ifiiity employee duties. Individuals assuming the duties of the facility employee on and after October 13, 2018 must be trained bxyy i•rr; performing facility employee duties . i -- • ;}; �p�,�r this box if a list of the individuals) trained is appended to this form. The appended list, at a minimum, must contain i. a7 of .M a information in this section. Date of Assuming Name of individuals) Trained $GcuNr Initial Training Date Responsibility as a IlrMt4ttIA CA47C Facility Employee -12 b 2x� fJ H l 26 ILk 7 126 2a 12. Ln o 10 10A004 10A004 S '-7t .,� � 16�► 1 I2. 0 2. 1 I o (2c ` 'l to � 2Cl ( 4 I0 '2. 0 1� Iv. CERTIFICATION BY DESIGNATED UST OPERATOR CONDUCTING THIS TRAINING The facility employees listed above have completed the required training in accordance with California Code of Regulations, We 23, Division 3, Chapter 16, Section 2715(c) and all the Information provided herein is accurate. Training Designated UST Operator Signature Date of Training CERS = CaSfnn is ErnaonmenW Reporing System, ID = Identification. ICC = imam fional Code Council, UST = Undemnxuxl Storage Tank