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W <br />W <br />W <br />rAppendix Xii <br />Underground Storage Tank, <br />Facility Employee Training Certificate (Page I of 1) <br />I . _ FAMI ITY 1r4FnPMATan <br />Business Name (Sarre as Facility Dame or DBA -Doing Business As) � Cj(E//Rb..,)S ID <br />Business Site Address ( � � city ZIP Code <br />i_�_ _e'n'_rr e Ic )=)n <br />It. DESIGNATED UNDERGROUND ,STORAGE TANK, 0PIEi AT00 IWORMATION <br />Name of Designated UST Operator Providing Training (Print as shown on the ICC: Certffication) <br />Evangelina Barroso-Traylor <br />rrraur► sy rtiuue caa a s rv� sc *r <br />3960 Gruenhagen Flat Paso Robles, Ca 909 455 Z2T5 _ <br />_ <br />ICC Certification #� ICG Certification Expiration Date <br />8200889 02/2812023 <br />EiteAr►rt S"f`ii MAM I f%V=c Wr-r9i'� AwTEfXl41 <br />.}.w ..�...... w........� . w....., $ ...,.... ....., <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. t <br />El Check this box if a list of the individual(s) trained <br />is appended to this <br />form. The appended list at a I <br />minimum must contain all of the information in <br />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 />t cddayn L_ c_,\ k <br />� � <br />2 1 1 <br />2 2 <br />7-9 21 <br />1-29,x. <br />° <br />IV. ' . CEftTtFlCATIQN BY DESIGNATED <br />UST OPERATOR C ND!lGTING TMS TRAINIRd <br />The facility employees listed above have completed the required training in accordance withsti <br />Ts4En 94 rlariainr+'! i`h aintr 4R Cese*,fi�rr ?7trinl arsif SEE #hcx <br />of ptrEa#wnnsa a <br />li�Eifnrft l"ntEn errr <br />y*»iM}iitY VVMV V} }RM is Mini}iii iii, tW}V k1iV, 11✓iiiV iVik Y, Vkkiitl iVi V, +yyVi♦Vii Y[ M'�V� 11(ikM Mkt i}}V <br />information provide herein Is accurate. _ M <br />T ing Desig 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 />