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Appendix X11 <br /> Underground Storage Tank <br /> Facility Employee Training Certificate ( Page 1 of 1 ) <br /> is FACILITY INFORMATION <br /> Business Name ( Same as Facility Name or DBA -Doing Business As) CERS ID <br /> H&S Energy Products , LLC # 3081 10594654 <br /> Business Site Address City ZIP Code <br /> 6633 Pacific Ave. I Stockton 195207 <br /> II . DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br /> Name of Designated UST Operator Providing Training (Print as shown on the ICC Certification) <br /> Romy Quiroz <br /> Mailing Address Phone # <br /> 328 Old River dr. Vallejo ca, 94589 707853-7854 <br /> ICC Certification # ICC Certification Expiration Date <br /> 52802MUC 09/28/2022 <br /> 111 . FACILITY EMPLOYEE INFORMATION <br /> Individuals assuming the duties of the facility employee before October 13 , 2018 must be trained <br /> within 30 days of performing facility employee duties . Individuals assuming the duties of the facility <br /> employee on and after October 13 , 2018 must be trained before performing facility employee duties . <br /> ® Check this box if a list of the individuals) trained is appended to this form. The appended list at <br /> a minimum must contain all of the information in this section. <br /> Date of Assuming <br /> Name of Individual (s ) Trained Initial Training Date Responsibility as a Facility <br /> Employee <br /> Joanna Varzant 1 /21 /2022 1 /21 /2022 <br /> N. CERTIFICATION BY DESIGNATED UST OPERATOR CONDUCTING THIS TRAINING <br /> The facility employees listed above have completed the required training in accordance with <br /> California Code of Regulations , Title 23 , Division 3 , Chapter 16 , Section 2715(c) and all the <br /> information provide herein is accurate. <br /> Training DesignOgg Operator Signature Date of Training <br /> ago AA 1 /21 /2022 <br /> CERS = Calif rnia Environmental Reporting System , ID = Identification , ICC = International Code <br /> Council , UST = Underground storage tank <br />