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Appendix XII <br /> Underground Storage Tank <br /> Facility Employee Training Certificate (Page 1 of 1) <br /> _ 1, FACILITY INFORMATION <br /> 3i Business Name (Same as Facility Name or DBA -Doing Business As) CERS ID <br /> Business Site Address City ZIP Code <br /> �.oltA) tcN (lvao/ LAY —1q 5 t`t L <br /> II. DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br /> Name of Designated UST Operator Providing Training (Print as shown on the ICC Certification) <br /> Jesse Diaz <br /> Mailing Address Phone# <br /> P.O. Box 26210 Oklahoma City OK 73126 405-687-1060 <br /> ICC Certification# ICC Certification Expiration Date <br /> 8261019 12/17/2023 <br /> III. 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 individual(s) trained is appended to this form. The appended list at a <br /> 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 /> -/-i <br /> VI igen/ 2l� �L <br /> IV. 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 Designated UST Operator Signature Date of Training <br /> LGA <br /> HERS = California Envi onmental Reporting System, ID = Identification, ICC = International Code <br /> Council, UST= Underground storage tank <br />