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UNDERGROUND STORAGE TANK <br />FACILITY EMPLOYEE TRAINING CERTIFICATE (page 1 of 1) <br />�l. FACILITY INFORMATION �— <br />CERS ID <br />Business Name (Same as Facility Narne or DSA -Doing Business As.) 10180561 <br />Escalon Mini Mart ZIP Code <br />Business Site Address City <br />1097 E Yosemite Ave Escalon 95320 <br />II. DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br />Namo of Qesignated U5T Operator Praviding the Training (Pant as shown on the ICC Certification.) <br />IL4 [�t7t <br />Phone # <br />Mailing Address 209 537 - 9396 Ext. <br />2825 Railroad Ave. Ceres, CA. <br />[CC Certification Expiration Date <br />tCC Certification # <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 facility <br />employee dutie& 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 list of the Individual(s) trained is appended to this form. The appended list at a minimum must contain all of the <br />information in this section. <br />Initial Training Date Date of Assuming <br />Responsibility as a <br />Name of Individual(s) Trained Facility Employee <br />Balwinder Singh . Before 1012018 Before 1012018 <br />Baban Kaur <br />Debra <br />Before 1012018 � Before 1012018 <br />8/1012020 8/10/2020 <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 information provide herein is accurate. <br />Traini et ST peratorSignature <br />Date of Training <br />CERS = California Environmental Reporting Systems, ID = Identification, ICC = tntematlonal Code Council, UST a Underground storage tank <br />