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UNDERGROUND STORAGE TANK <br /> FACILITY EMPLOYEE TRAINING CERTIFICATE (Pago i of 1) <br /> I. FACILITY INFORMATION <br /> Business Name(Same as Facility Namo or DBA-Doing Bushess As) CERS 10 <br /> Ryder-Truck Stockton 1 10181387 <br /> Business Sire Address Cily ZIP Code <br /> 3633 Duck Creek Dr. Stockton 95215 <br /> II. DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br /> Nance of Designated u5T operator Providing She Training{Print as shown on rho ICC Corlificnrion.) <br /> James Keltner <br /> Mailing Address Phone# <br /> 930 Ames Ave. Mil itas,Ca 95035 40$ 942-8686 <br /> ICC Certification# ICC Cerlificalion Fxpifallon Dale <br /> $178558-UC 12l5I2026 <br /> III. FACILITY EMPLOYEE INFORMATION <br /> Individuals assuming the duties of the facility employee before October 13,2t018 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 individual(s)trained is appended to this form. The appended list,at a minimum,must contain <br /> all of the information in this section. <br /> Date of Assuming <br /> Name of Individual(s)Trained Initial Training Date Responsibility as a <br /> Facility Employee <br /> TNT o�jz���' 09 ollzy <br /> V r_ti1a � � — j Iz <br /> IV. CERTIFICATION BY DESIGNATED UST OPERATOR GONDUCTING THIS TRAINING <br /> The facility employees listed above have completed the required training In accordance with California Code of Regulations, <br /> Titie 23,Division 3,Chapter 16,Section 2715(c)and all the Information provided herein Is accurate. <br /> Training oesignaled UST Operator Signature Date of Training <br /> 91 117I2025 <br /> CERS=California Enmurneri al Reporting System,10=identification,ICC=International Code Council,UST=L n*mjw d Storage Tank <br /> UN-112 www.unidocs.org Ill-Rev.10101118 <br /> CamScanner <br />