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5 <br />Appendix XII <br />Underground Storage Tank <br />Facility Employee Training Certificate (Page 1 of 1) <br />FACIE !TY WFORNIATION � <br />Business Name (Same as Facility ERS ID <br />Name or DBA -Doing Business As) CC i �3 C� <br />t <br />[�itiess Site Address �\ City ZIP Code <br />C l'�UY� W\re v^ �--�1 i C;c <br />II DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br />Name of Designated UST Operator Providing Training (Print as shown on the /CC Certification) <br />Evangelina Barroso-Traylor <br />tV� tom. Tf'",Qi'I'] r%%AU, ass 455 2275 <br />A R..'t�. Ig A Ad f....+.. �09 <br />3960 Gruenhagen Flat Paso Robles, Ca <br />C Certification Expiration Date <br />ICC Certification # =02/2812023 <br />8200889 <br />CA /" f iTV ltilf]t` f%VCC fA1C�1 lllit l►Tiflw <br />aar. ar�vfr.ss ■ r..less r.vas..>.srwr vsat�srsssys� <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 />❑ 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. <br />Date of Assuming <br />Name of Individual(s) Trained Initial Training Date Responsibility as a Facility <br />Employee <br />cr n r X VAC <br />�2_ 5 -1 S <br />2, -I& I <br />29.20 <br />lC) 2-"-2G <br />IV. CE TIFI+CATION BY DESIGNATED UST OPERATOR -CONDUCTING THIS TRAINING <br />The facility employees listed above have completed the required trainingin accordance with <br />�VA�i~+.thel <br />tv v'Scr.V\V1Mthe <br />. <br />Iinformation provide herein is accurate. <br />Trng Desig d UST Operator Signature Date of Training <br />C IV _C%� — \ \ ..j <br />CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br />Council, UST = Underground storage tank <br />