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Appendix XII <br /> Underground Storage Tank <br /> Facility Employee Training Certificate (Page 1 of 1) <br /> I. FACILITY INFORMATION <br /> Business Name (Same as Facility Name or DBA -Doing Business As) CERS ID <br /> Jahant Food&Fuel Stop 16161611 <br /> Business Site Address City ZIP Code <br /> 24323 N Hwy 99 Acampo 195220 <br /> I1. DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br /> Name of �nated <br /> UST O �ator Providing Training (Print as shown on the ICC Certification) <br /> Mailing Address Phone# <br /> PO Box 933,West Sacramento,Ca 95605 916-371-2380 <br /> ICC Certification# ICC I�CertificationExpirati22 0� <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 /> [rl Check this box if a list of the individual(s) trained is appended to this form. The appended list at <br /> a 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 /> Jagwinder Singh 3/14/14 3/1/14 <br /> Jatinder Singh 1/19/23 2/11/23 <br /> Makhan Singh 3/14/14 2/16/14 <br /> \A <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 D signs d UST Operator Signature JD�a�te7o_f Training <br /> 3-2 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council, UST= Underground storage tank <br />