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W <br />W <br />Appendix X!i <br />Underground Slorage Tank <br />Facility Employee Training Certificate (Page 1 of 1) <br />. -FAC- fTY 1WORRAt!0 <br />Business Name (Same as Facility Name or D -Doing Business As) CERS ID <br />tl`._-1 _ 10 t "ISO -1 -S <br />__ _ <br />Business Site Address �°City ZIP Code <br />1 GUat - a ry-N m le k a <br />II: IGN TED UNDERGROU"D STo AGE TANK oRlb 14' t IN RIMA' to !i <br />Name of Designated UST Operator Providing Training (Print as shown on the /CC Certification) <br />Evangelina Barroso-Traylor <br />IY;Qlkk/ t1� f'\ttLll G�� t t tVt ESi >T I <br />3960 Gruenhagen Flat Paso Robles, Ca 909 455 2275 31j1 <br />ICC Certification # ICC Certification Expiration Date <br />8200889 02/28/2023 <br />4 rt1 c w f4i fTV C&AM MMIC 1AWOMAN n 1F'E nisi <br />:... ..,.t �. .�. . ►. a 1AWOMAN �w.r...VIA ...., <br />_ . <br />. <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 />O Check this box if a list of the individual(s) trained is appended to this form. The appended list at a <br />minimum must contain all of the information in this section. _ E <br />Date of Assuming <br />Name of Individual(s) Trained Initial Training Date Responsibility as a Facility <br />Employee <br />C� <br />2Co 2 <br />C�n a. <br />� n' �`� ' t 8 <br />l d• 2 2- l 8 <br />l+ Y <br />IV. CERTfi= CATION OY Mi ' [? <br />UST gPERATORc+ <br />NDUCTING TIMa TRAINING <br />The facility employees listed above have completed the required training in accordance with <br />' vviitfviiiiM vd�v w v+ viw�akiwar t. , iv �, miry eriv:v+i w, v�iK�*w 44w, <br />information provide herein is accurate. --- <br />T ing Desi "ed UST Operator Signature - Dateof Training <br />!Y— <br />l4 <br />CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br />Council, UST = Underground storage tank <br />