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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 Name or DBA-Doinrg Business As.) <br />=CERS <br />Escalon Mini Mart <br />City ZIP Code <br />Business Site Address 95320 <br />1097 E Yosemite Ave Escalon <br />11. DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br />Name of pesignated UST Operator Providing the Training (Print as shown on the ICC Certification.) <br />Phone # <br />Mailing Address 209 537 - 9396 Ext. <br />2825 Railroad Ave. Ceres, CA. <br />ICC Certification # ICC Certification Expiration bate <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 duties. Individuals assuming the dutles 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 file individual(s) trained is appended to fiiis form. The appended list at a minimum must contain all of file <br />El information in this section. <br />Name of individual(s) Trained <br />Balwinder Singh <br />Baban Kaur <br />Debra <br />Kim Cruise <br />IV. CERTIFICATION BY DESIGNATED U <br />Initial Training bate <br />Before 1012018 <br />Before 1012018 <br />8/1012020 <br />Before 1012018 <br />Date of Assuming <br />Responsibility as a <br />Facility Employee <br />Before 10/2018 <br />Before 1012018 <br />8/10/2020 <br />Before 1012018 <br />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 />----]-Training D �E d U Aerator Signature Date of Training <br />CERS = California Environmental Reporting Systems, ID = Idendffcatfon, ICC = International Code Council, UST = Underground storage tank <br />