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UNDERGROUND STORAGE TANK <br /> FACILITY EMPLOYEE TRAINING CERTIFICATE (Page 1 of 1 ) <br /> I . FACILITY INFORMATION <br /> Business Name (Same as Facif Name or DBA-Doing Business As.) CERS ID <br /> � 1 - 3o- 0�1 ZZ� B — G-t �/ 101 8 � b (e5 <br /> Business site Address City ZIP Code <br /> S'�iQ C!(TU rJ 9 5Ze q <br /> II . DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br /> Name of Designated UST Operator Providing the Training (Print as shown on the ICC Certification.) <br /> Andrea Evans <br /> Mailing Address <br /> P . O . Box 6004 , Attn : Permit Desk , San Ramon , CA 94583 hon 699 ow 2648 Ext. <br /> ICC Certification # ICC Certification Expiration Date <br /> 10148220 1 / 1q / 024 <br /> III. FACILITY EMPLOYEE INFORMATION <br /> Individuals assuming the duties of the facility employee before October 13, 2018 must be trained within 30 days of performing facility <br /> employee duties. Individuals assuming the duties of the facility employee on and after October 13, 2018 must be trained before performing <br /> facility employee duties . <br /> Check this box if a list of the Individuals) trained Is appended to this form. The appended list at a minimum must contain all of the <br /> information in this section. <br /> Initial Training Date Date of Assuming <br /> Name of Individuals) Trained Responsibility as a <br /> Facility Employee <br /> i 07 <br /> Mai c )e..i T� 1Iii '1'I/ti w � <br /> ( 1 Z 1 z0 lot <br /> IV CERTIFICATION BY DESIGNATED UST OPERATOR CONDUCTING THIS TRAINING Regulations , <br /> ce <br /> th <br /> ired The facility emplin acco <br /> oyees listed above have completed <br /> the requi the nforrnatlonnprovide herein <br /> rdais acciuratCalifornia <br /> i o <br /> Th ty <br /> title 23, diva on 3 , chapter 16 , section 2715 (c) a Date of Training <br /> \2 � � Zo2Z. <br /> it <br /> Tr Hing De To erator nature <br />