Laserfiche WebLink
e" <br />Appendix XII <br />Underground Storage Tank <br />Facility Employee Training Certificate (Page 1 of 1) <br /># FOIE'.## #'Fly WFORWATION I <br />Business Name (Same as Facility Name or DBA -Doing BusinessA=CERS :1� <br />CA q <br />Business Site Address City ZIP Code <br />1`� Cowl � rr, <br />UNDERGRout4D STORAGE TANK OpER,47pR lid ORMATION <br />It. DESIGNATED <br />Name of Designated UST Operator Providing Training (Print as shown on the ICC Certification) <br />Evangelina Barroso-Traylor <br />�Y�a�fi g 'A't ��� %JI IV <br />909 455 2275 <br />3960 Gruenhagen Flat Paso Robles, Ca <br />ICC Certification # ICC Certification Expiration Date <br />8200889 02/28/2023 <br />Hl. V A /`it rYv 'G94pi'' ewc 1030 1OM AN <br />Asa. a rM%V11-s it * 66.1991126.199112�vasi�er+• s'1"�fv� <br />the duties of the facility employee before October 13, 2018 must be trained <br />Individuals assuming <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 individuals) trained is appended to this form. The appended list at a <br />minimum must contain all of the information in this section <br />+� <br />Date of Assuming <br />Name of Individual(s) Trained <br />Initial Training Date <br />Responsibility as a Facility <br />Employee <br />CERTIFICATION BY DESIGNATED UST OPERATOR COIVUucTING THIS?RAINING <br />IV. <br />The facility//employees above hawve completwed the required training in accordanFcFe(�-with <br />%t.ed <br />M�:TvMf�:� VVMV V: PVy.VRV, T.#fn `C' 1`.V.VR S' rV.�, <br />information provide herein is accurate. <br />T i ing Design UST Operator Signature <br />Date of Training <br />CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br />Council, UST = Underground storage tank <br />