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UNDERGROUND STORAGE TANK <br /> FACILITY EMPLOYEE TRAINING CERTIFICATE ( Page 1 of 1 ) <br /> I . FACILITY INFORMATION <br /> Bu fess Name (Same as Fa ility Name or DBA-Doin Business As.) CERS ID <br /> 09 7z- ( (0 (0l0 <br /> Business Site AddrE$ City ZIP o . <br /> l6 � .s � Ut W -tWVL , �l 5` t ( V- zl �( <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 Phone # <br /> P . O . Box 6004 , Attn : Permit Desk , San Ramon , CA 94583 209 699 - 2648 Ext . <br /> ICC Certification # ICC Certification Expiration Date <br /> 10148220 <br /> 1 / 13 / 024 <br /> III . FACILITY EMPLOYEE INFORMATION <br /> remployee <br /> viduals assuming the duties of the facility employee before October 13 , 2018 must be trained within 30 days of performing facility <br /> duties . Individuals assuming the duties of the facility employee on and after October 13, 2018 must be trained before performing <br /> lity employee duties . <br /> Check this box if a list of the individual(s) 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 Individual (s) Trained Responsibility as a <br /> Facility Employee <br /> -� - <br /> i <br /> --� <br /> IV CERTIFICATION BY DESIGNATED UST OPERATOR CONDUCTING THIS TRAINING <br /> The facility employees listed above have completed the required training in accordance with California Code of Regulations , <br /> title 23 , divisi 6 3 , chapter 16 , section 2715 (c ) and all the information provide herein is accurate. <br /> Date of Training <br /> Tr ning De ' na d Operator Signatur ' <br />