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v zT _ CI) (D <br /> o ° Ozt <br /> o 0o G <br /> m C) � Nv <br /> N y N (D <br /> O `< <br /> D <br /> M UNDERGROUND STORAGE TgNK ° <br /> = FACILITY EMPLOYEE TRAINING CERTEFICATE(Pag©i of 1) ° (n <br /> I (Q (D <br /> Businass Narne(Sarrre as pecifi 1' FACILITY INFORMATION 7 G <br /> West Valle A; to ty emaorDBq_poingBusrnassAsl (7 � <br /> Business Site gdtlress Service CERS ID 0) <br /> 2615 West Grantline Rd. City r <br /> 10184725 ZIP Code (D r <br /> If. Trac 95034 7�? � <br /> DESIGNATE <br /> DUN C-) <br /> STORAGE TANK OPERATOR INFORMATION 4< <br /> Name of Desl,hid 1157 Operator providing the Training(pony as shown on iha 1CC CanrlrceffonJ <br /> Rick 8ranchini <br /> n Mailing Address <br /> CD <br /> 106 Wessex Way Folsom, CA 95630 CL CrI <br /> Phone# <br /> n 11 Certification i 925 699-1398 ° <br /> r 8164986 ICC Certification Expiration Dale � <br /> n 6/2/2022 A <br /> fli. FACILITY EMPLOYEE INFORMATION ]? <br /> n Individuals assumingthe duties of the facility employee before October 13,2018 must be trained within 30 days of performing ` <br /> facifi employee g C <br /> tY plo ee duties.Individuals assuming the duties of the facility employee on and after October 13,2018 must be trained <br /> before performing facility employee duties. r <br /> 21 Check this box if a list of the individuals trained is a CD <br /> CD <br /> all of the information in this section, <br /> f 1 appended to this form. The appended list,at a minimum,must contain <br /> Q <br /> Data of Assuming <br /> Name of Individual(s)Trained Initial Training Date Responsibility as a <br /> Facility Employee <br /> n <br /> See Suppleme=ntal Employee Training Roster 1�s <br /> I fakimi Wais 10/1/2016 D <br /> ;a � z co <br /> Sayeed Emran 711/2017 cn <br /> w <br /> CD <br /> Cassie Lazer 2 y 1 211 1201 8 <br /> 12L3-19-- <br /> Rocky Durani 2 11!112020 <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 provided herein is accurate. <br /> Training De UST Ope t re Date of Traini g �J <br /> 0 <br /> 0 <br /> Q <br /> s? <br /> CERS=Caiflm Erniiorrrier W Rep,"S}glefn,ID a BandoiliOn,ICC=Irdertta6Dnel Code Courd,UST=Unde mond&,-age <br /> UN-112 www.unidocs.org <br /> m 111 -Rev.10101118 0 <br /> O 01 <br /> fV <br /> (31 <br /> W <br /> v <br />