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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/Dame or DBA-Doing Business As) CERS ID <br /> PILOT/ FLYING J TRAVEL PLAZA#1017 - LATHROP 10726990 <br /> Business Site Address City ZIP Code <br /> 345 ROTH ROAD LATHROP 95330 <br /> If. DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br /> Name of Designated UST Operator Providing the Training(Print as shown on the ICC Certification.) <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-U C 8/1/2022 <br /> III. 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 /> 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 /> El 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 /> 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 info ion provided herein is accurate. <br /> Training Designated UST Operator Signature Date of Training <br /> j L Iii Z, Z J2.1 <br /> CERS=Califomia Environmental Reporting System,ID=Identification,ICC=International una7,UST=Underground Storage Tank <br /> UN-112 wvwv.unid rg 111 -Rev.10/01/18 <br />