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UNDERGROUND STORAGE TANK <br />FACILITY EMPLOYEE TRAINING CERTIFICA,rE (Page 1 of 1) <br />- I. FACILITY INFORMATION <br />siness Name (same as Factiity Ivarne or DBA -Doing Business As.) CERS ID <br />,talon Mini Mart I lot S <br />Business Site Address City ZIP Code <br />1097 E Yosemite Ave Escalon 95320 <br />II. DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br />Name of Designated UST Operator Providing the Training (Print as shown on the ICC Certification.) <br />Mailing Address <br />2825 Railroad Ave. Ceres, CA. <br />ICC Cer0cation # <br />Phone # <br />(209) 537 - 9396 Ext. <br />Date , , <br />8 /9 -N 0 /r_b Z <br />III, FACILITY EMPLOYEE INFORMATION <br />Individuals assuming the duties of the facility employee before October 13, 20'18 must be trained within 30 days of performing facility <br />employee duties. Individuals assuming tho duties of the facility employee on and after October 13, 2018 must be trained before performing <br />facility employee duties. <br />n Check this box if list of the individual(s) trained is appended to this form. The appended list at a Ininimum must contain all of the <br />information In this section. <br />initial Training mate Date of Assuming <br />Name of Individual(s) Trained Responsibility as a <br />Facility Employee <br />IV. CERTIFICATION BY DESIGNATED UST OPERATOR CONDUCTING THIS TRAINING <br />'she 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 />Training Desig d U5_T-Opgr`afgr Signature —Pit-- <br />0/7-0 <br />at <br />0 fz0 z -D <br />u:-1 r -d. r`„, ~il I LST = I InelP_rormind stnrace tank <br />