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r <br />Appendix X11 <br />Underground Storage Tank <br />Facility Employee Training Certificate (Page 1 of i) <br />J <br />Business Name (Sarre as Facility Name or DBA -Doing Business As) GERS ID <br />Business Site Address City ZIP Code <br />I!... DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INF'ORMAT119N <br />Name of Designated UST WOperator Providing Training (print as shown on the /CC Cern iicationJ j <br />Evangellna Barroso-Traylor <br />its .I- ..R .t..t — l l I two . # <br />WiQOi i rrvrtc rr <br />L3�9�60�Gru�enhagenFlat Paso Robles, Ca 909 455 2275 <br />ECC Certification # ICC Certification Expiration Date <br />8200888 02/28/2023 <br />[## C A f" !! #'T'V a'A1l�! f"1yc #Rl�k'1!3 #i# A Ttf" t!R# <br />v�.VV t a..AAs%s . yrI&A �� • evr� <br />Individuals assuming the duties of the facility employee before October 13, 2018 must be trained <br />within 30 days of performing facility employee duties. Individuals assuming the duties of the facility <br />employee on and after October 13, 2018 must be trained before performing facility employee duties. <br />'a[ <br />D Check this box if a list of the individual(s) trained is appended to this fort. The appended list at <br />minimum must ,contain all of the information in this section. ..__. i <br />Date of Assuming <br />Trained <br />Name of Individual(s) a <br />Initial Training Date <br />g <br />Responsibility as a Facility <br />Employee <br />IV. CERTWICATION BY DESIGNATED <br />UST OPERATOR CONDUCTING TMS TRAINNG� <br />The facility employees listed above have completed the requilrRed training gin accordance with <br />! <br />�allf^rwtf : MV w Y ilV :w:a�..4 lvi1M, i Mi'Vs MCI- V1^t1v�a.W 4Yt Ya�iVFiv[� <br />information provide herein is accurate. <br />T `ning Desi ed UST Operator Signature Date of Training <br />CERS = California Environmental Reporting System, ID = Identification, ICC = international Code <br />Council, UST = Underground storage tank <br />