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UNDERGROUND STORAGE 'DANK <br />FACILITY EMPLOYEE TRAINING CERTIFICATE (Page 1 of 1) <br />I. FACILITY INFORMATION <br />siness Name {Same as Facility Name or OBA-Doing Business As.) CER1 ID <br />calon Mini Mart I I (DI S _ <br />Business Site Address City ZIP Code <br />1097 E Yosemite Ave EscaIon 95320 <br />If, DESIGNATED UNDERGROUND STORAGE TA14K OPERATOR INFORMATION <br />Name of Designated UST Operator Providing the Training (Print as shown on the FCC Certification.) <br />yC V-tz-Lf &A"61ZELL <br />Mailing Address Phone # <br />2825 Railroad Ave. Ceres, CA. {209 537 - 9,196 Ext. <br />ICC Certification #n J- f 1CC CertiiicatioTi Expiration €date <br />7"� 9 ! 6/1 Y/i3 <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 facility <br />employee duties. Individuals assuming the duties of the facility employee on and after October 13, 2018 must be trained before performing <br />facility employee duties. <br />Check this box if a fist of the fndividual(s) trained is appended to this form. The appended list ata minimum must contain all of the <br />information In this section. <br />Name of Individual(s) Trained <br />v <br />Initial Training Date Date of Assuming <br />Responsibility as a <br />Facility Employee <br />'b -r _�e.r <br />-� da <br />1 t`)' - <br />IV. CERTIFICATION BY, DESIGNATED UST OPERATOR CONDUCTING THIS TRAINING <br />—he facility employees listed above have completed the required training in accordance with California Code of Regulations, <br />23, division 3, chapter 16, section 2715(c) and all the information provide herein is accurate. <br />9/G/z,1 rL_ <br />!`Hilo rsu inril I MT= I Indr mrrmnd stOraae tank <br />