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Appendix XII <br /> Underground Storage Tank <br /> Facility Employee Training Certificate (Page 1 of 1) <br /> I. FACILITY INFORMATION <br /> --- -- - - <br /> �I Business Name (Same as Facility Name or DBA -Doing Business As) CERS ID <br /> L__ L cjvc'1 -rr,,.,,c rk Q 'q" 10448341 <br /> Business Site Address City ZIP Code <br /> 11. DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br /> Name of Designated UST Operator Providing Training (Print as shown on the ICC Certitication) <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 /> 0 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 /> Gtr LI W-ter <br /> Cre m is 3 3 i-L <br /> y-I-,q <br /> Z-U-Zp1 <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"U71 perator Signature Date of Training <br /> -/ a-,,Z <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council, UST = Underground storage tank <br />