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UNDERGROUND STORAGE TANK <br /> FACILITY EMPLOYEE TRAINING CERTIFICATE (Page 1 of 1) <br /> I. FACILITY INFORMATION <br /> Business Name(Same as Facility Name or DBA-Doing Business As) CERS ID <br /> PILOT / FLYING J TRAVEL PLAZA#1017 - LATHROP 1 10726990 <br /> Business Site Address City ZIP Code <br /> 345 ROTH ROAD I LATHROP 195330 <br /> II. DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br /> Name of Designated UST Operator Providing the Training(Print as shown on the ICC Certffrcation.) <br /> UST OPERATORS OF SOUTHERN CALIFORNIA- LANCE YORK <br /> Mailing Address Phone# <br /> 21352 SILVERTREE LN., TRABUCO CANYON, CA 92679 949 230-8931 <br /> ICC Certification# ICC Certification Expiration Date <br /> 5296385-UC 8/1/2022 <br /> Ill. FACILITY EMPLOYEE INFORMATION <br /> Individuals assuming the duties of the facility employee before October 13,2018 must be trained within 30 days of performing <br /> facility employee duties.Individuals assuming the duties of the facility employee on and after October 13,2018 must be trained <br /> before performing facility employee duties. <br /> Ei Check this box if a list of the individual(s)trained is appended to this form. The appended list,at a minimum,must contain <br /> all of the information in this section. <br /> Date of Assuming <br /> Name of Individual(s)Trained Initial Training Date Responsibility as a <br /> Facility Employee <br /> LAW Z_ 5 %- � -� _z <br /> R©6 7 -[n.7, 1 0 --a <br /> �(�►tir� �tCV <br /> IV. CERTIFICATION BY DESIGNATED UST OPERATOR CONDUCTING THIS TRAINING <br /> The facility employees listed above have completed the required training in accordance with California Code of Regulations, <br /> Title 23, Division 3,Chapter 16,Section 2715(c)and all the inMnation provided herein is accurate. <br /> Training Designated UST Operator Signature Date of Training <br /> "'�'6L� 1 Z 1 Z/ <br /> CERS=Caifomia Environmental Reporting System,ID=Idwtification,KL ntemation Cound,UST=Underground Storage Tank <br /> UN-112 www.unidoet.org 1h-Rev.10/01/18 <br />