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tbftdE*4TA W" <br />N <br />FA 'Aft.Y.-Em 11FICAT <br />PLOVE A OZ. Ejeaoe I of til <br />WIOPM n... qw-. <br />7 7 7- ]MRS 10 <br />T <br />me tar-acHay Narrie or Busfnow As.) <br />FIS2 - I <br />. CPrqA_5DaW;_- !-&L- C4 zip Code <br />Business 86e' dress 0, C' A I <br />M&A\tc <br />N M Ev <br /><.bP'l5RAT01kJNF0RMAT-10N <br />as &WWn on <br />Erik Hirtojose Phone # <br />Milling Address <br />PO Box 1394 Lafayette, CA 94549 (888) 500 - CHtK Ext, <br />9209377 06/2912021 <br />L <br />Individuals assuming the duties of the facility employee before October 13, 2098 must be trained within 30 days of performing facility <br />employee duties. lndlvlduals assuming the dutles of the facility employee on and after October 13, 2018 must be trained before performing <br />facility employee duties. <br />check thl &box Na-11st of the indWdual(s) trained is appended to this form. The appended list at a MIMMUM Must c0frWin all Of the <br />Information In this section. <br />Name of IndMdual(a) Trained RespCinotbility ab A <br />I FaOIRY Employee <br />$ f zS <br />ni <br />111 <br />*Z1 <br />ILI <br />Ell ZZ I , 1) lLil <br />CERVIR -MQN'I3Y0ESldNATEQ.-'U <br />The facility employees listed above have completed the required training in accordance with California Code of Regulations, <br />title 23, division 3. chapter IS, section 2715(c) and all the Information provide herein Is accurate. <br />Training -Designated UST Operator Slonaturo Date of ria n mg <br />EmimrnetU Reporting Sysuwks, ID a Identification, ICC a MffWWW Code Council- UST = Undargrourd storage tank <br />