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UNDERGROUND STORAGE TANK <br /> FACILITY EMPLOYEE TRAINING CERTIFICATE(Page 1 of 1) <br /> Businessfame(Same as acil Name or DBADoingBunn ss <br /> AACILITY INFORMATION <br /> t- CERS ID <br /> Business Site Address <br /> ^ W Cin' ZIP Code <br /> 11. DESIGNA ED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br /> Name of Designated UST Operator Providing the Tr ining( rint as shown on the ICC Certification.) <br /> 1 <br /> Mailing AddressAeS_ I ; <br /> PO Box 933, West Sacramento, Ca 95605 Phone# <br /> ICC Certification# 916 371-2380 <br /> 2 ` ICC Certification Expiration Date <br /> III• FACILITY EMPLOYEEINFORMATION <br /> Individuals assuming the duties of the facility employee before October 13,2018 must be trained within 30 days of performing <br /> facility employee duties.Individuals assuming the duties of the facility employee on and after October 13,2018 must be trained <br /> before performing facility employee duties. <br /> Check this box if a list of the individuals)trained is appended to this form. The appended lis4 at a minimum,must contain <br /> all of the information in this section. <br /> Name of Individual(s)Trained Date ofAssuming <br /> Initial Training Date Responsibility as a <br /> S yl Facility Employee <br /> I crL g <br /> 7-3 <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,Division_" Cftdpter 16,Section 2715(c)and all the information provided herein is accurate. <br /> Training Desigp'ated UST Op`er for Signature <br /> �DaterofTringrai /J <br /> CERS=Cafiforno En-onmentN Rep—Q System,ID=ldenfificafion,ICC=International Code Coundi UST_U <br /> r>der9round Storage Tank <br />