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Appendix XII <br /> Unde <br /> rground Storage Tank <br /> Facility Employee Training Certificate (page 1 of 1) <br /> I• FACILITY INFORMATION <br /> � f <br /> 3usin ss Name (Same as Facility NamejorDBA,j-Doi�2 Business As) CERS ID <br /> 0 ��Business Site AddressCity ZIP Code <br /> Lc1 D <br /> II. DESIGNATED UNDERGROUND STORAGE TANK OPERATORSN L <br /> 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 <br /> 405-687-1060 <br /> ICC Certifica=_# � ICC Certification Expiration Date j <br /> 8261019 12!17/2023 <br /> rwithin <br /> ;thb <br /> TY EMPLOYEE INFORMATION I <br /> ing the duties of the facility employee before October 13, 2018 must be trained <br /> performing facility employee duties. Individuals assuming the duties of the facility <br /> after October 13, 2018 must be trained before performing facility employee duties. j <br /> x if a list of the individuals) trained is appended to this form. The appendedlist ata <br /> ontain all of the information in this section. i <br /> Date of Assuming <br /> Name of Individual(s)Trained Initial Training Date Responsibility as a Facility <br /> Employee <br /> 4-1 -L <br /> a`e, <br /> 6' <br /> I <br /> i <br /> f <br /> 1 , <br /> rinmaitbion <br /> CERTIFICATION BY DESIGNATED UST OPERATOR CONDUCTING THIS TRAINING <br /> y employees listed above have completed the required training in accordance with { <br /> Code of Regulations, Title 23, Division 3, Chapter 16,Section 2715(c) and all the <br /> provide herein is accurate. <br /> Training Designated pe or Signature Date of Training <br /> L/ <br /> CERS = California E ronmental Reporting System, ID = Identification, ICC = International Code <br /> Council, UST= Underground storage tank <br />