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F <br /> UNDERGROUNDSTORAGETANK RECEIVED 6/29 <br /> /2022 <br /> FACILITY EMPLOYEE TRAINING CERTIFICATE(Page i of 1) <br /> Business Name(same as Facility Name or DBA_ I' FACILITY INFORMATION <br /> Kwik SerV BIN 113 Doing Business As) <br /> Business Site Address I-Odl CERS ID <br /> 420 Kettlernan Lane 10181407 <br /> City ZIP Code <br /> l) DESIGNATED Lodi 95240 <br /> Name of Designated UST Operator Providin UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br /> Renee Jo Arnaiz 9 the Training(Print as shown on the ICC certification.) <br /> Mailing Address <br /> P.O. Box 162 Lodi, CA. 95241 Phone# <br /> ICC Certification# 209 518-4836 <br /> 8032295 ICC Certification Expiration Date <br /> 11/24/2022 <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 <br /> facility employee duties.Individuals assuming the duties of the facility employee on and after October 13,2018 must be trained <br /> before performing 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 <br /> all of the information in this section. <br /> Date of Assuming <br /> Name of Individual(s)Trained Initial Training Date Responsibility as a <br /> Facility Employee <br /> - c� <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 lations, <br /> Title 2 ion 3, Chapter 16, Section 2715(c)and all the information provided herein is accurate. <br /> � Date of Tr Hing <br /> Trail-Ling sig ted UST Op rat r Sig t re 6/10/2022 <br /> (( r <br /> ID=�ernfication.ICC=Int onal Code Counal,UST=Underground Storage Tank <br /> CERS=Cat mmE!WFor1nX%hal System, . idocs.org ill -Rev.iwetml <br /> UNA 12 <br />