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Appendix XII <br /> Underground Storage Tank <br /> Facility Employee Training Certificate (Page 1 of 1) <br /> as 1. FACILITY INFORMATION <br /> Business Name ( ame as Facility Name or DBA -Doing Business As CERS ID <br /> G" ( s 9 ) �y <br /> S3 � � o y y � <br /> Business Site Address <br /> � S Z city ZIP Code <br /> S 0 N, ��a�r�dh a Lp 0 CIS 7-q Z. <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 <br /> P•O. Box 26210 Oklahoma City OK 73126 Phone# <br /> ICC Certification # 405-687-1060 <br /> 8261019 ICC Certification Expiration Date <br /> 12/17/2023 <br /> Ill. 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 Assum <br /> Name of Individual(s)Trained Initial Training Date Responsibility as alng Facili <br /> ty <br /> Employee <br /> -2--to <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 De ' ed ST Operator Signature Date of Training <br /> 3/31/2022 <br /> CERS = Ca . mia Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council, UST= Underground storage tank <br />